Unlike the declining prevalence of several cardiovascular risk factors such as high blood pressure and high cholesterol, the public health burden of diabetes is increasing. The increased risk of diabetic patients after acute coronary syndrome (ACS) creates a management challenge. This risk is conferred by several metabolic alterations at the level of the vascular endothelium, of the thrombotic cascade as well as at the inflammatory level. This diabetic population may be the one that benefits the most from various therapies, such as significant platelet inhibition, and an early invasive strategy. Despite the documented efficacy and the evidence from the recommendations, diabetic patients with ACS remain treated less frequently than patients without diabetes.