Abstract: ［Abstract］Objective This study aimed to assess the adherence to guideline-recommended therapies according to risk stratification in the management of acute coronary syndrome（ACS）. Methods We analyzed 1，001 consecutive patients admitted with ACS. Patients were stratified using the GRACE risk score into low- and high-predicted risk of mortality at 6 months. We evaluated the use of hospital angiography，revascularization，and guideline-recommended medications between high and low-risk patients. Results High-risk compared to low-risk patients were less likely to underwent coronary angiography and/or revascularization during the hospitalization. The use of hospital-initiated pharmacotherapies was also lower in high-risk patients（P＜0.05）. Advanced age，increased creatinine level and higher GRACE score were independent predictors for failure to administer evidence-based therapies. Conclusion Patients with ACS at high risk of mortality were paradoxically less likely to undergo revascularization or receive medications according to guidelines. Better adherence to evidence-based therapies in high-risk patients may improve clinical outcome and quality of health care.