Acute coronary disease remains a major cause of morbidity and mortality. Investigation in established and novel therapies aimed at treating acute coronary syndromes continues. The resulting increase in available options will present a significant challenge to practitioners determining the optimal regimen for specific patients. The addition of newer, more potent antiplatelet agents, such as prasugrel and possibly ticagrelor, will require careful patient selection and risk assessment for both recurrent ischemic events and bleeding. The likely addition of newer oral anticoagulants will require knowledge as to their specific characteristics and risk/benefit ratios. Incremental updates to guideline recommendations from established expert groups will be important in providing guidance.