The platelet is central to the pathophysiology of acute coronary syndromes (ACS) via its direct participation in the formation of the thrombotic occlusion and its participation in the coagulation cascade that results in the formation of thrombin. Antiplatelet therapy is a cornerstone of therapy in the setting of ACS. Unfortunately, many patients who receive intensive antiplatelet therapy remain at high risk for recurrent events. Current efforts to reduce this "residual risk" include lifestyle modifications, cardiac rehabilitation, and intensive therapy for dyslipidemia. Also being investigated are methods of individualizing and intensifying antiplatelet therapy. Novel compounds that promise to reduce recurrent ischemic events without an increase in bleeding events are being evaluated in clinical trials. This review summarizes ongoing efforts to improve the effectiveness of antiplatelet therapy among patients with ACS.