BACKGROUND: With 7 million deaths per year, ischaemic heart disease is the leading cause of mortality worldwide. In Acute Coronary Syndrome (ACS), the vast majority of fatal cardiovascular events occur after hospital discharge. Guidelines recommend antithrombotic treatment for secondary prevention after ACS.   OBJECTIVES: To assess the cost-effectiveness of rivaroxaban 2.5mg BID in combination with standard antiplatelet therapy (ASA alone or in combination with a thienopyridine [clopidogrel or ticlopidine]) versus standard antiplatelet therapy alone for prevention of secondary events in ACS patients from a Swedish societal perspective. METHODS:  A Markov model is used to capture single and multiple events, costs and utilities based on the time since index event to reflect clinical practice. For the first 2 years the model uses data from the ATLAS ACS 2-TIMI 51 clinical trial including efficacy, safety, treatment discontinuation and average patient age. After 2 years, transition probabilities were extrapolated using an exponential function method. Estimates for life expectancy, drug acquisition costs and other medical and indirect costs were derived from published Swedish sources. Cost and effects are discounted at 3.0%. Univariate and probabilistic sensitivity analyses were conducted with an assumed willingness to pay (WTP) threshold of SEK 500,000. RESULTS: For the base case scenario, incremental life time costs are estimated at SEK 10,000.44 (€1,156), incremental QALYs at 0.14, and incremental cost per QALY at SEK 71,245.76 (€8,236). Univariate sensitivity analyses indicate that the results are sensitive to changes in the cost of rivaroxaban and baseline utility value. At an assumed WTP of SEK 500,000, rivaroxaban in combination with standard antiplatelet therapy is expected to be cost-effective. CONCLUSIONS: From a Swedish societal perspective, secondary prevention with rivaroxaban 2.5mg BID in combination with standard antiplatelet therapy can be considered a cost-effective option for patients with ACS. Sensitivity analyses demonstrated that the results are robust.