Objective. To analyze in-hospital, mid-term and long-term outcomes of various treatment strategies for acute coronary syndrome after previous coronary artery bypass grafting. Material and methods. The study included 81 patients who underwent coronary artery bypass grafting (CABG) in 2006—2016. Acute coronary syndrome (ACS) occurred within various periods after surgery. Percutaneous coronary intervention (PCI) was made in 34 patients, medication was prescribed in 45 patients, two patients underwent redo CABG. In-hospital, annual and 3-year incidence of major adverse cardiovascular and cerebrovascular events (death from all causes, myocardial infarction (MI), repeated revascularization and acute cerebrovascular accident) was assessed. Redo CABG was not included in the study due to small sample size. Results. Patients with ACS with ST elevation made up 4.4% in the medication group and 20.6% in the PCI group (p=0.025), ACS without ST elevation — 95.6% and 79.4%, respectively (p=0.025). GRACE score in patients with ACS without ST elevation in the medication group was 88 (81; 108), in the PCI group — 98 (84; 115). Low risk patients with ACS without ST elevation made up 76.7% in the medication group and 59.3% in the PCI group; intermediate risk patients — 18.6% and 33.3%, respectively, high-risk patients — 4.7% and 7.4%, respectively (p=0.3). In-hospital mortality in the medication group was 2.2%, in the PCI group — 2.9% (p=0.84). Annual survival was 97.8% and 97.1%, respectively (p=0.84). Three-year survival did not exceed 93.3% and 94.1%, respectively (p=0.89). In-hospital MI in the medication group occurred in 6.7% of patients, in the PCI group — 23.5% (p=0.032). There were no repeated MIs at the in-hospital stage and in annual follow-up in both groups. Three-year incidence of MI in the PCI group was 2.9%, in the medication group these cases were absent (p=0.25). In-hospital strokes were absent in both groups, whereas annual incidence of this event was 2.9% in the PCI group (p=0.25), over a three-year period — 4.4% and 2.9%, respectively (p=0.73). Emergency including repeated revascularization at the hospital stage was not registered in both groups, annual incidence was 4.4% and 20.6%, respectively (p=0.025), 3-year incidence — 6.7% and 32.4%, respectively (p=0.003). Conclusion. Patients with ACS after previous CABG is a complex cohort of patients requiring a special approach for determining the indications and type of repeated myocardial revascularization. An integrated approach should include a detailed analysis of the anatomical and angiographic parameters and dynamics of residual SYNTAX score (from the initial value after CABG up to the moment of ACS), type of ACS and risk measurement. Conservative therapy has shown favorable outcomes in patients with low-risk ACS without ST elevation after previous CABG over 3-year follow-up. Similar favorable results are observed in case of PCI in the native arteries and coronary bypass grafts among intermediate risk patients with ACS without ST elevation and ACS with ST elevation. Overall 3-year survival rate in patients with ACS after previous CABG exceeds 93%.