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We describe the prevalence and prognostic significance of heart failure (HF) complicating acute coronary syndromes (ACS) in patients enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE).Gulf RACE is a prospective, multi-national study of all patients hospitalized with ACS in 65 centres in six Arab countries. Data were analysed based on HF on presentation (Killip class II/III) or during hospital stay. The study endpoint was all-cause in-hospital mortality. Of 8000 patients with ACS, 2009 (25%) had HF on presentation or during the hospital stay. Patients with HF were older, more often with co-morbid conditions, and less often treated with evidence-based therapies. Heart failure was associated with higher in-hospital mortality (7.9 vs. 0.9%, P < 0.001), which persisted after adjusting for age, gender, and presentation and treatment characteristics [adjusted odds ratio 4.1 (1.8–9.4)]. There was a significant interaction between age and the prognostic effect of HF on in-hospitality mortality, such that younger patients had a significantly higher increase in mortality related to HF (P for interaction=0.002).Heart failure complicates a substantial proportion of ACS admissions in the Arab Middle East and is associated with higher in-hospital death. Younger patients with ACS have a higher relative increase in mortality related to HF.