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Background Subclinical hypothyroidism is associated with adverse cardiovascular outcomes.But less is known about its prognostic role in patients with acute coronary syndrome (ACS).Methods 538 ACS patients with normal serum concentrations of T3 and T4 underwent coronary angiography in our hospital from January 2015 to January 2019 were retrospectively enrolled.They were divided into normal thyroid stimulating hormone (TSH) group (0.27-4.2 uIU/mL) (n=385) and high TSH group (＞4.2 uIU/mL) (n=135).The study endpoints were the major adverse cardiovascular events (MACEs).The univariate and multivariate regression analysis including significant covariables were performed to test for the association between subclinical hypothyroidism and MAC-Es.Results The mean concentration of TSH were 8.72 (6.37-11.02) uIU/mL in the high TSH group and 1.94 (1.34-2.45) uIU/mL in the normal TSH group.Multivariate logistic regression analysis found that subclinical hypothyroidism[Odds ratio (OR): 1.94,95％ confidence interval (CI): 1.23-2.65,P=0.030]was associated independently with MACE rate in ACS patients.The area under the receiver operating characteristic curve showed that the subclinical hypothyroidism had good predictable value for MACEs in patients with ACS (area under the curve:0.713,95％ CI: 0.668-0.802,P＜0.001).Conclusions Subclinical hypothyroidism is associated with worse clinical prognosis in ACS patients.Clinicians need to pay more attention to subclinical hypothyroidism in ACS patients.