Objectives: To determine the frequency of different acute coronary syndrome (ACS) presentations and their outcomes in diabetic patients and gender based difference. Methodology: This cross sectional study was conducted in Cardiology Department of Khyber Teaching Hospital, Peshawar from 1st January to 31st July 2018. Diabetic patients admitted via emergency department presenting with acute coronary syndrome were included .The patients were followed during their hospital stay for complications like left ventricular failure, recurrent angina and mortality. All the variables were addressed according to gender difference.  Chi-square test was used for final analysis. P< 0.05 was considered statistically significant. Results: A total of 388 diabetic patients were included. Of them males were 217 with mean age of 60.64 ± 9.24 years. About 65.46% patients presented to us with acute myocardial infarction. Thrombolytic therapy was done in 78.74% patients. About 86 males and 61 females developed symptoms of heart failure post MI (p < 0.001). In hospital mortality was found to be significant according to gender, p = 0.03. About 48.27% and 44.44% male patients presented with NSTEMI and USA respectively with no significant difference compared to females (p =0.21). However results were significant for stable angina [35.29% females vs.  64.70% males, p <0.001]. Conclusion: Diabetic patients present with coronary artery disease and its complications with heart failure and death more common among males as compared to females, needing special consideration for diagnosis and treatment.