Background and Objective: The diagnosis, management, and treatment of the non-ST-segment elevation acute coronary syndromes (NSTE-ACS), which include non-ST-segment elevation MI, and unstable angina (UA), have been rapidly evolving in recent years. Our study aimed to examine the management of NSTE-ACS in the cardiovascular department of Cairo University and to compare adherence to 2011 focused update of ACC/AHA 2007 guidelines for management of UA/NSTEMI.Methods: In this prospective observational registry, 310 adults hospitalized with a diagnosis of NSTE-ACS were enrolled between August 2011 and July 2012 at the cardiovascular department of Kasr Alainy hospital. Data on patient characteristics, treatment, and outcomes were collected. Guidelines adherence scores were calculated.Results: NSTEMI was the initial diagnosis in 45.5% of the patients. During hospitalization, degree of adherence to Guidelines for individual drug therapy was high for Clopidogrel (97.7%) Beta blockers (91.3%), anticoagulants (93%) and a lipid-lowering medication (100%), whereas it was suboptimal for Aspirin (72.9%), ACE-I/ARBs (61%). The initial invasive strategy adopted in 71% of all patients and in 75.8% of high risk patients. The in-hospital management, discharge medication and composite adherence scores were 83.3%, 83.4% and 83.9% respectively. In-hospital mortality was 6.1% (n=19). In-hospital major bleeding was 2.9% (n=9). Predictors of non-adherence to Guidelines in in-hospital management were CKD, CRUSADE score > 40 and prior CABG. Predictors of in-hospital mortality were Killip class III-IV, advanced age, the initial conservative strategy in high risk patients and elevated troponin. Predictors of in-hospital major bleeding were high CRUSADE score and low Hematocrite value.Conclusion: : In this observational study of patients with ACS, Rates of adequate adherence to recommendations related to acute pharmacotherapy and discharge medications are satisfactory. However, full adherence was suboptimal (25% for acute pharmacotherapy and43% for discharge medications, Adherence to guidelines recommendation related to aspirin and ACEI/ARBs is suboptimal. Although invasive management strategy was adopted in a significant proportion of patients, 25% of high risk patients were deprived from invasive strategy. . in-hospital mortality rate in our registry is high when compared to contemporary international registries. Similarly, our registry has higher rate of cardiogenic shock (4.2%) with high mortality rate (75%). These findings reveal the importance of Periodical evaluation of real-life practice in comparison to guideline adherence aiming at further improvement of the medical service and consequently the outcome.