- Background Historically gender differences existed in treatment and outcome of patients with acute myocardial infarction (MI). Aim To assess gender aspects of contemporary treatment and adherence to ACC/AHA Class-I Treatment Guidelines in patients with acute coronary syndrome (ACS). Methods We studied 2024 consecutive patients (519 women, 26%); 1026 (51%) with ST-elevation (STE)-MI and 998 (49%) patients with non-STE (NSTE), during a nationwide ACS-survey, conducted during 2-months in 2004. Results Women were older than men (71 vs. 59 in STEMI; 71 vs. 64 years in NSTE-ACS patients), and had worse cardiovascular risk profiles. In STEMI-patients, acute reperfusion was less frequent in women than in men (53% vs. 63%, respectively, p = 0.01; non-significant after age-adjustment). At discharge, fewer women received ACE-inhibitors/ARBs (71% vs. 75%, respectively; ORage-adj = 0.69[0.48–0.98]). Among NSTE-ACS patients, fewer women received IIb/IIIa-inhibitors (12% vs. 21%, respectively, p = 0.007; ORage-adj = 0.58[0.36–0.96]) and clopidogrel at discharge (49% vs. 59%, respectively, p = 0.005; ORage-adj 0.75[0.56–1.01]). No gender differences were noted in utilization of aspirin, beta-blockers or statins. Age-adjusted and covariate-adjusted mortality rates were comparable in women and men with STEMI (at 7-days 4.3% vs. 4.1%; ORadj = 0.95[0.47–1.87] and at 1-year 13.8% vs. 9.8%, hazard ratio [HRadj] = 1.11[0.73–1.70], respectively); in women and men with NSTE-ACS (at 7-days 1.3% vs. 2.1%, ORadj = 0.65[0.20–1.76], and at 1-year 12.0% vs. 11.3%; HRadj = 1.19[0.80–1.77], respectively). Conclusions In 2004, adherence to ACC/AHA Class-I Treatment Guidelines in ACS-patients was satisfactory. Relative underutilization of acute reperfusion was noted among STEMI patients, without gender differences after age-adjustment. At discharge, less women received ACE-inhibitors/ARBs. Among NSTE-ACS patients, less women than men received IIb/IIIa-inhibitors, and clopidogrel at discharge. Contemporary ACS management was associated with similar adjusted outcome in women and men.