Heart rate (HR) is a key prognostic and modifiable risk factor in patients with acute coronary syndrome (ACS), yet comparative real-world data on different HR-lowering strategies remain limited. This prospective observational study evaluated the efficacy and safety of bisoprolol, ivabradine, and their combination in adult patients with ACS admitted to a tertiary care hospital. Over a six-month period, 50 patients were included and categorized according to in-hospital therapy: bisoprolol monotherapy (n = 17), ivabradine monotherapy (n = 17), or combination therapy (n = 16). The primary outcome was change in HR from admission to discharge, while secondary outcomes included changes in systolic and diastolic blood pressure (BP) and the incidence of adverse drug reactions (ADRs). All treatment groups demonstrated significant within-group HR reduction (p < 0.05). Between-group comparison revealed a statistically significant difference in HR reduction (one-way ANOVA, p = 0.018), with combination therapy achieving the greatest mean reduction. Bisoprolol was associated with significant BP reduction, whereas ivabradine showed a largely BP-neutral profile. ADRs were infrequent and mild; hypotension occurred only in the combination group, while bradycardia was limited to monotherapy groups. The study is limited by its observational design, small sample size, and short follow-up. Overall, bisoprolol remains effective for HR and BP control in ACS, while ivabradine, alone or in combination, offers a welltolerated option for enhanced HR reduction in selected patients.