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Introduction: This study aimed to ascertain the prevalence of metabolic syndrome (MetS) in patients from Hungary and Iraq, suffering from acute coronary syndrome (ACS) and investigate the effects of MetS on hospital outcomes, in particular mortality and its relation to differences in patients' baseline characteristics. Material and methods: A prospective cohort study was conducted in two cardiac centers between May 2018 and May 2019. It included 164 consecutive ACS patients: 64 patients from the Cardiac Clinic in Pécs, Hungary and 100 patients from Al Nassiryah Heart Center, Iraq. Baseline characteristics, clinical management, and in-hospital and 30-day post-discharge outcomes were recorded. Results: Prevalence of metabolic syndrome among ACS patients in Iraq? was not significantly higher than in Hungary (25.0% vs 34.1%; P = 0.306). There were no significant differences in age between those with and without MetS (64.2 vs 63.3 years; P = 0.394). MetS was associated with a higher median BMI (28.0 vs 23.7 kg/m 2 ; P < 0.001), hyperlipidemia (37.8% vs 12.8%; P < 0.001), hypertension (48.8% vs 27.4%; P = 0.024), high cholesterol (5.4 vs 4.1 mmol/L; P < 0.001), high LDL-C (3.5 vs 2.6 mmol/L; P < 0.001), and high triglycerides (1.4 vs 1.1 mmol/L; P < 0.001). MetS was associated with a higher risk of out hospital re-infarction (12.8% vs 3.7%; P = 0.031) and MACE (17.7% and 6.1%; P = 0.027). Conclusions: Current study did not show any significant difference in the incidence of MetS between ACS patients in the two countries. But patients with MetS were significantly more likely to be associated with MACE (P = 0.027).