Since the introduction of clotting factor concentrates over 50 years ago the life expectancy of patients with hemophilia (PWH) has increased to over 70 years. Consequently, diseases of the ageing population, including coronary artery disease, are increasingly being encountered. These patients present a unique therapeutic problem due to their greatly increased bleeding risk. Randomized controlled studies specific to PWH are lacking, emphasizing the need for case series. We present three cases of acute coronary syndrome in PWH who underwent urgent percutaneous coronary intervention at our institution, and summarize the available literature on the topic. We describe their management and outcome and provide points to consider when treating these complex patients.