An initial acute coronary event is an important predictor of future cardiovascular events and all-cause mortality in patients with chronic kidney disease. The aim of this study was to identify an association between acute coronary events during the predialysis phase of chronic kidney disease and major adverse cardiac events in patients initiating maintenance haemodialysis. One hundred sixty-nine patients initiating maintenance haemodialysis were enrolled in this study. In the subsequent follow-up period (median: 60 months), subjects experiencing an initial major adverse cardiac event were compared with those who did not have such an event on the basis of several clinical parameter measurements at the end of the predialysis phase. A history of an acute coronary event was present in 21 patients (12%), and these patients had a higher cumulative major adverse cardiac event rate during follow-up than subjects without a history of acute coronary event (75 vs 19%, P < 0.001). Multivariate Cox regression analysis showed that the following four parameters independently predicted major adverse cardiac events: a history of acute coronary events (hazard ratio, 4.19; 95% confidence interval, 1.61 to 8.13; P < 0.001), presence of diabetes (hazard ratio, 7.70; 95% confidence interval, 3.29 to 23.83; P < 0.001), each 1 g/dl increment in haemoglobin (hazard ratio, 1.57; 95% confidence interval, 1.23 to 2.34; P = 0.002) and each 1 kg/m(2) decrement in body mass index (hazard ratio, 0.80; 95% confidence interval, 0.72 to 0.98; P = 0.005). In conclusion, these results suggest that a history of acute coronary events, presence of diabetes, increased haemoglobin concentration or decreased body mass index at the end of the predialysis phase were significantly associated with the occurrence of a major adverse cardiac event in patients initiating maintenance haemodialysis.