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To assess the prevalence and predictors of posttraumatic stress symptoms in patients at 12 and 36 months post hospital admission for an acute coronary syndrome (ACS). There is increasing recognition that posttraumatic stress may develop in the aftermath of an acute cardiac event. However, there has been little research on the longer-term prevalence of posttraumatic stress disorder (PTSD).Posttraumatic stress symptoms were assessed at 12 months in 213 patients with ACS and in 179 patients at 36 months. Predictor variables included clinical, demographic, and emotional factors measured during hospital admission.At 12 months post ACS, 26 (12.2%) patients qualified for a diagnosis of PTSD; 23 (12.8%) patients were identified with PTSD at 36 months. Posttraumatic symptoms at 12 months were associated with younger age, ethnic minority status, social deprivation, cardiac symptom recurrence, history of depression, depressed mood during admission, hostility, and Type D personality. In multiple regression, depressed mood during admission and recurrent cardiac symptoms were independent predictors of posttraumatic symptoms (R2 = 0.507, p < .001). At 36 months, posttraumatic stress symptoms were independently predicted by posttraumatic symptom levels at 12 months and depressed mood during admission (R2 = 0.635, p < .001).Posttraumatic stress symptoms persist for at least 3 years after an acute cardiac event. Early emotional responses are important in predicting longer-term posttraumatic stress. It is important to identify patients at risk for posttraumatic stress as they are more likely to experience reduced quality of life.