OBJECTIVES: Acute coronary syndrome (ACS) is the most important clinical consequence of coronary artery disease and a leading cause of death worldwide. This study aims to assess the costs of ACS from a social and health insurance perspective evaluating direct costs, production losses and intangible costs in terms of quality adjusted life years (QALYs) lost. METHODS: A bottom-up incidence approach was used. ACS-Patients with one or more ACS events were extracted from a national hospital database and from mortality statistics. Remaining life years of surviving patients were modelled on age, gender and life expectancy statistics. Inpatient costs include acute care and rehabilitation in 2008. Outpatient costs include costs for ambulance, visits to GP and cardiologist, outpatient diagnostics, medication and rehabilitation. Production losses were calculated according to the human capital approach, including absenteeism, permanent disability and premature death. Intangible costs were calculated based on literature data. Cost data are derived from official price lists, literature and experts. Validation of clinical data was conducted using the AMIS-PLUS registry. RESULTS: A total of 14,955 patients experienced a total of 16,815 ACS events in 2008; 2,752 died as a consequence of these. This resulted in 19,064 hospital stays with an average length of stay in acute care of 8.9 days per patient. Total direct costs amounted to 690 Mio Swiss Francs (CHF) for the society and 523 Mio CHF for health insurers. Forty-four percent belong to inpatient and 56% to outpatient services. Production losses were 515 Mio. CHF and intangible costs resulted in 37,457 QALYs lost. Average total direct costs and production losses per patient were 80,873 CHF. Results appear robust in sensitivity analysis. CONCLUSIONS: ACS causes considerable costs in terms of direct medical expenditures, lost production and premature death, even without taking into account costs for its chronic consequences such as congestive heart failure.