Patients with end-stage renal disease have a poor prognosis. An acute coronary syndrome (ACS) is the most common cause of death in patients on hemodialysis. Acute coronary occlusion, a primary intimal disease characterized by the thrombus due to rupture of a vulnerable atherosclerotic plaques, is the most frequent underlying cause of ACS. In hemodyalysis patients, heavy calcification of the plaques and striking medial thickness of the coronary artery are also characterized as a dominant morphological change. Therefore the effect of reperfusion therapy was inadequate for these patients. The long-term prognosis has been improved by recent new coronary arteries intervention (Rotablator^TM) and operation method (off-pump CABG), but is still poor. The end-stage renal failure has been already considered to have the most serious risk factor of ACS in U. S. A., and elucidation of risk factors and a guideline for prevention were publicized. Data about these conditions should be accumulated immediately, and more aggressive prophylactic procedures must be investigated in our country.