Cancer patients with acute coronary syndrome (ACS) have significantly greater mortality compared with non-cancer patients. This risk is partly directly attributable to the malignancy; however these patients are frequently undertreated with respect to guideline recommended treatments for ACS due to higher bleeding risks from anemia and thrombocytopenia. Due to exclusion from large clinical trials, there is a paucity of data regarding how to best treat these complex and high-risk patients. PURPOSE OF REVIEW: To review the literature and identify risk factors among cancer patients associated with poor outcomes, pathophysiology of chemotherapy and radiation therapy contributing to accelerated coronary artery disease and ACS, and data regarding outcomes with medical therapy and invasive management. RECENT FINDINGS: Despite an elevated bleeding risk, many cancer patients may benefit from ACC/AHA guideline-directed management for ACS including aspirin, P2Y inhibitor, statin, and beta-blocker therapies. Cancer patients with ACS are a uniquely vulnerable population who are often undertreated, and with improved cancer treatments, this population is expected to increase. These patients should be included in future randomized trials to better understand how to balance the complexities of increased bleeding and thrombosis risks during ACS.