There are several differences in trans-C18:1 positional isomers between acute coronary syndrome (ACS) and control. • Palmitelaidic acid, ruminant-derived TFA were lower in ACS patients, especially middle-aged patients. • Linoleic trans isomers, industrially-produced TFA (IP-TFAs) were higher in ACS. • IP-TFA to arachidonic acid (AA) ratio was significantly higher in ACS, especially elder ACS patients. • Palmitelaidic acid was significantly directly associated with HDL-C, EPA+DHA, and EPA+DHA/AA ratios.