In this article, we review the impact of gender on the pathophysiology, management and outcomes after acute coronary syndrome (ACS). We searched the English-language literature indexed in MEDLINE, Scopus and EBSCOhost Research databases from 1988 through January 2009 using the indexing terms 'gender', 'short- and long-term outcomes' and 'acute coronary syndrome' and 'myocardial infarction'. Data comparing gender differences in outcomes after ACS showed that females have a higher mortality rate than males. Observational studies showed that guideline-recommended management strategies are used significantly less frequently in females than males. The undertreatment and worse outcome of female patients with ACS are probably multifactorial and have been reported in different ethnicities and cultures. However, there are conflicting data regarding to the impact of gender on early versus long-term outcomes, the benefit of early intervention in low- and high-risk females and the influence of unmeasured selection biases in the use of therapies in the observational data. These gender discrepancy trends warrant close follow-up, as this might reflect changes in primary and secondary prevention in the community. Furthermore, gender discrepancy gives an indication of healthcare quality and whether care is given in an unbiased manner. All high-risk females, and males with ACS, should receive optimal medical management, coronary angiography and revascularization whenever indicated.