OBJECTIVES: To estimate the cost and Quality Adjusted Life Years of tirofiban, abciximab and eptifibatide plus standard care versus standard care alone in ST-elevated myocardial infarction and Non ST-elevated (NSTE) Acute Coronary Syndrome (ACS) in England and Wales. METHODS: A lifetime state transition model was constructed to conduct a cost utility analysis comparing low dose (for first 30 minutes, 0.4mg per minute, followed by 0.1 micrograms per kg per minute thereafter) tirofiban, standard dose abciximab (initially 250 micrograms per kg, followed by 125 nanograms per kg per minute thereafter) or standard dose eptifibatide (initially 180 micrograms per kg, followed by 2 micrograms per kg per minute) added to standard care in two populations: primary percutaneous coronary angioplasty in STEMI and an Early Invasive strategy in medium to high risk NSTE ACS.  Relative Risks of death, bleeding, myocardial infarction and urgent revascularisation came from a systematic review.  Probabilistic sensitivity analysis was performed. RESULTS: In STEMI, tirofiban plus standard care dominated the other interventions in both with or without future unrelated illness cost. The Incremental Cost Effectiveness Ratio (ICER) versus standard care only varied from approximately £1150 to £9,000. In NSTE ACS, eptifibatide plus standard care dominated the other interventions: the CER versus standard care varied from £1100 without to £7700 with unrelated illness costs. CONCLUSIONS: The addition of tirofiban to standard care in STEMI is likely to be cost effective when a low dose bolus was administered followed by continuous low dose infusion during primary percutaneous coronary angioplasty.  In the medium to high risk NSTE ASC population, eptifibatide could be cost effective. However, there is much uncertainty in many parameters in both target groups, largely due to lack of randomised controlled trial evidence.  We recommend consideration of further research, particularly larger trials.