OBJECTIVES:  To estimate the costs to manage bleeds in hospitalized acute coronary syndrome (ACS) patients in Germany treated with antithrombotics, antiplatelet, and fibrinolytic therapies. treated with antithrombotics, antiplatelet, and fibrinolytic therapies. METHODS:  Retrospective hospital chart review of ACS patients identified with one of following bleeds: symptomatic intracranial haemorrhage (IH), retroperitoneal haemorrhage (RH), gastrointestinal haemorrhage (GH), decrease in Hb greater or equal to 3 g/dL (DH), puncture site bleed (PS), or transfusion of greater than or equal to 2 units of blood product.  Reason for admission, length of stay (LOS), diagnostic procedures, and transfusion related resources were counted and costed using unit estimates based upon German DRGs and procedures. Bleed related LOS was calculated using the reported date of bleed until discharge. RESULTS:   Records of 61 consecutive ACS patients were included in the study.  Average age was 68.6 with 60% males. Patients were classified as: 1 IH, 3 RH, 10 GH, 14 DH, 31 PS and 2 with transfusions. The average LOS ranged between 6 and 13.5 days but ranged up to 23 days.  The average bleed-related LOS ranged from 5 to 12 days.  Average costs by type of patient classification were: IH €3739, RH €5467, GH €5172, DH €3336, PS €3380, transfusions €6366.  Average cost overall patients was €3879 of which €3004 occurred after the bleed date.  LOS and resource use details allow hospitals to estimate their own internal costs of antithrombotics, antiplatelet, and fibrinolytic therapies. CONCLUSIONS:  German hospitals are paid by case severity and diagnosis of patients.  Understanding the full costs of managing ACS patients and avoiding bleeds may help control hospital costs.