Background: Acute Coronary Syndromes(ACS) represent a continuum of disease ranging from unstable angina, associated with reversible myocardial cell injury, to ST-segment elevation of myocardial infarction, associated with irreversible myocardial necrosis [1][2]. It represents the acute life threatening phase of coronary artery disease (3). Current knowledge regarding the characteristics, treatments and outcomes of patients diagnosed with the complete spectrum of acute coronary syndromes is limited to data derived from clinical trials and/or from national registries. Acute coronary syndrome patients enrolled in randomized, clinical trials are a highly selected, lower-risk subgroup. Hence, unless the trial is very large and heterogeneous, it tends to reflect an ‘ideal’ study set rather than the diversity of clinical practice. (4) Objective: To better delineate the change in the characteristics, treatments, and outcomes of patients with (ACS) by comparing current results with those of previous local registries that have been done in the past years. Methods: This study was performed in the National Heart Institute CCU and Kasr Einy hospitals, including a total of 1807 patients diagnosed as having acute coronary syndrome. 606 patients were collected prospectively (group 3) and compared with 1201 patients collected retrospectively from previous national registries performed in the national Heart Institute from 2007(group 1) to 2010 (group 2). Data of all patients included: Full history taking including risk factors, full clinical examination, ECG, echocardiography management including modality of reperfusion, adjunctive medical treatment and whether coronary angiography+/- PCI was done or not; outcome and in hospital mortality. Result: percentage of STEMI increased among those presenting with ACS. (from 59% in G1 vs. 63% in G2 reaching almost 74% in G3) P<0.001. The mean ages were 54.5 +/- 11.8 G1, 56.9 +/- 10.6 in G2, and 54.3 +/- 10.9 in G3. Significant drop in mean age occurred G2 vs. G3 (P=0.001). Gender distribution hasn’t change significantly. Smoking and diabetes increased with no statistical significance. Patients with previous PCI increased significantly 5% in G1 5.6% in G2 reaching 12% in G3 (P=0.001). Coronary Angiography increased from 40 % in G1 to 52% in G3(P<0.001) . PCI was done to 48.3 % of admitted patients of G3 vs. 22% in G2 (P<0.001) and 26% in G1 (P<0.001). Primary PCI has increased significantly 12.36% G1 (P=0.001), 13% G2(P=0.001) , and almost 40% G3. Door to needle (DTN) and door to balloon (DTB) showed no statistical difference. DTN 20 +/- 8 min G1 vs 21.5 +/- 7.3 minutes (P=0.105), while DTB 102 +/- 10.9 min G1 vs. 101.5 +/- 26.6 min (P=0.86). Overall complications have decreased significantly. Mortality has improved, 4.24% G1 vs. 2.5% in G3 (P=0.044) .Conclusion: Smoking, Hypertension, and diabetes are significant risk factors, which increased over the past years. This finding necessitates the formulation of programs for primary and secondary prevention of coronary artery disease. The intervention strategies have seen some flourishment. The percentage of PCI increased significantly, but still thombolysis is the primary reperfusion modality. That shows the need for developing our insurance system to cover a broader spectrum with more services.