Coronary specialists (cardiology and surgical) are often faced with patients with acute coronary syndrome (ACS) and surgical pattern coronary disease and a spectrum of stability and risk. These patients fall into a watershed zone of evidence between the impulse to revascularise quickly with PCI (percutaneous coronary intervention) for the acute ischaemia, but durably with CABG (coronary artery bypass grafting) surgery for the long-term outcome. Initial targeted PCI can incur delays in performing safe durable CABG as stents “bed in” with dual antiplatelets. Equally some patients may be too unstable and the heart too irritable to withstand surgery. Such patients therefore require a tailored approach accounting for multiple factors including coronary anatomy and lesion characteristics, comorbid conditions, institutional expertise and facilities, patient preferences, haemodynamic stability, and symptoms. This chapter aims to discuss and inform the reader about current evidence and rationale for the various approaches (conservative, PCI, CABG, and hybrid techniques). As the choice of best strategy in ACS with surgical pattern coronary disease is often complex involving several interacting variables, decisions should be guided by multidisciplinary heart team discussion. Here we discuss revascularisation approaches and the factors to consider when selecting an optimal revascularisation strategy in this complex patient group.