Background Platelets have a chief role in the pathogenesis of acute coronary syndrome (ACS), where plaque rupture is followed by platelet activation and thrombus formation, leading to coronary artery occlusion. When platelets are activated, they become bigger in size, which can be measured by both mean platelet volume (MPV) and platelet distribution width (PDW). Aim The aim of this study was to evaluate the predictive value of blood count parameters, including platelet indices such as MPV, mean platelet component, plateletcrit, PDW, and mean platelet mass and blood cell ratios such as neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, white blood cell to mean platelet volume (WMR) in ACS. Patients and methods This work was carried out at the Clinical Pathology and Cardiology Departments at Assiut University Hospital during the period between January 2017 and December 2017. It included two groups of participants: 250 patients with ACS (patient group) and 100 apparently healthy age-matched and sex-matched individuals (control group). Results Mean age of the patient group was 57.41 ± 12.15 years, with range between 31 and 90 years old. Of 250 patients with ACS, 187 (74.8%) patients were males. The patient group had significantly higher MPV, PDW, WMR, and neutrophil-to-lymphocyte ratio in comparison with the control group, but the control group had higher mean platelet component and platelet-to-lymphocyte ratio (P Conclusion Low hemoglobin and increased RDW, MPV, and WMR were predictors for the development of major adverse cardiac event in patients diagnosed with ACS.