OBJECTIVES: To evaluate health care costs following acute coronary syndromes (ACS) in patients with/without recurrent cardiovascular events (CVEs). METHODS: Patients with ≥1 ICD-9 CM codes for acute myocardial infarction (410.xx) or unstable angina (411.1x) during ACS hospitalization were identified from the HealthCore Integrated Research Database January 1, 2006 to September 30, 2011 (index event date defined as first ACS hospitalization date). Patients with <12 months pre/post-index plan eligibility or <18 years old were excluded. Recurrent CVEs were defined as myocardial infarction, non-fatal stroke or coronary heart disease-related mortality. Total and CV-related hospitalization costs following index ACS were evaluated in patients with/without recurrent CVEs, adjusting for demographic characteristics, comorbidities, treatment utilization and index ACS characteristics. RESULTS: Of 140,903 US patients, 22.0% had ≥1 subsequent CVE during follow-up. Patients with versus without recurrent CVEs were older - and had more comorbidities. Mean (median) follow-up was 2.0 (1.6) and 1.9 (1.5) years in patients with and without recurrent CVEs, respectively. Mean (median) length of stay for index ACS hospitalization was longer in patients with versus without recurrent CVEs. Mean (median) 1-year post-index total and CV-related cost were higher in patients with versus without recurrence ($41,478 [$17,474] and $34,094 [$10,057] versus $30,608 [$17,241] and $23,613 [$10,336]; p<0.001). Inpatient hospitalization costs were the major driver of total expenditures, comprising 76% and 72% of total costs in patients with versus without recurrence, respectively. Mean 2- and 3-year post-index total and CV-related costs were also significantly higher in patients with recurrent CVEs (2-year: $27,746 and $20,572 vs. $18,707 and $12,794; 3-year: $21,880 and $15,260 vs. $14,438 and $9,049; p<0.001). CONCLUSIONS: Following ACS hospitalization, patients with recurrent CVEs incurred higher 1-, 2- and 3-year post-index event costs compared those without recurrence, underscoring the need to focus on the prevention of subsequent adverse CVEs following ACS to improve patient outcomes and reduce total health care cost.