Despite the high incidence of coronary artery disease in patients with renal impairment, its diagnosis and management remains difficult. The treatment of acute coronary syndrome in this particular group of patients is more complex than in patients with normal renal function. They have a high prevalence of asymptomatic cardiac ischemia. Abnormal baseline electrocardiogram (ECG) findings and nonspecific elevation of cardiac enzymes may be present. Studies are lacking regarding their management mainly because they have been excluded or were not studied as a subgroup in the clinical trials. Thrombolytics are underused during acute myocardial infarction. Heparin, mainly low-molecular weight heparin, for unstable angina and non-Q wave myocardial infarction, should be used with caution because the higher risk for bleeding. Other medications, such as aspirin, metoprolol, and nitroglycerin should be used as in the general population. The newer platelet glycoprotein IIb/IIIa inhibitors may need renal dose adjustment. Revascularization should be pursued if necessary by percutaneous coronary intervention or coronary artery bypass grafting. However, the prognosis and risk of revascularization versus medical therapy have not been determined yet.