OBJECTIVES: Aim of this study was to evaluate the average annual direct costs of treating patients with a recent admission for acute coronary syndrome (ACS). METHODS: Direct medical costs of patients with ACS (index event) in the period January 1, 2008 to December 31, 2008 and treated with dual antiplatelet therapy (clopidogrel+aspirin) were estimated in a one-year follow-up period. Resource consumption measured were: reimbursed drugs, diagnostic procedures, hospitalizations. The analysis was performed from the Italian National Health Service (INHS) perspective. RESULTS: A total of 2,758,872 subjects were observed; 7,082 (35.8% females) of these were hospitalized for ACS during the 1-year accrual period (2.6‰). Among patients with ACS, 60% were medically treated, 33.1% were treated with percutaneous coronary intervention (PCI) and 6.9% died during the first hospitalization. Dual antiplatelet treatment was prescribed in 25.9% of patients with ACS medically treated and in 70.1% of patients with ACS treated with PCI. During follow-up, all-cause mortality rate was 5.7% [33% for cardiovascular (CV) causes]; among the 58.6% of patients with at least one re-hospitalization, 18.4% had a recurrent episode of ACS, 24.8% had other CV episodes and 15.4% were hospitalized for non-CV reasons. Average yearly cost/patient for total ACS population was 12,673€/year (drugs: 1,896€,  hospitalizations: 10,315€, diagnostic: 462€). For patients with an index event of ACS medically treated, average annual cost was 11,043€/year (drugs: 1,968€, hospitalizations: 8,558€, diagnostic: 517€) and for patients with ACS treated with PCI, average annual cost per patient was 13,776€/year (drugs: 1,848€, hospitalizations: 11,492€, diagnostic: 436€). Hospitalization costs of patients with a relapse were at least 49% higher than for patients without events. Patients died for a CV event during follow-up had an average cost of 19,198€/patient. CONCLUSIONS: Patients with ACS had relevant costs of management being the need for a new hospitalization the major cost driver.