Aim To investigate the relationship between baseline monocyte to high density lipoprotein cholesterol ratio (MHR) and acute heart failure (AHF) in postmenopausal women with coronary heart disease (CHD). Methods A cohort of 180 postmenopausal women was enrolled, who were diagnosed as CHD by coronary angiography in Shantou Central Hospital (Shantou, China) from December 2014 to July 2016. The patients were categorized into two groups:fifty-five patients with AHF in hospital as AHF group, one hundred and twenty-five patients without AHF as control group. The relationship between MHR and AHF was assessed by Logistic regression analysis. Results MHR in AHF group (0.48(0.1,0.61))was higher than that in control group(0.35 (0.3,0.44)) (P＝0.005). MHR was negatively correlated with left ventricular ejection fraction (LVEF) by Spearman rank correlation analysis (r＝－0.304, P＝0.001) and partial correlation analysis by controlling for age(r＝－0.215, P＝0.005). The optimal MHR cut-off level for predicting AHF in postmenopausal women with CHD was 0.367 7 (specificity 70.6%, sensitivity 59.8%, area under the ROC curve 0.646, standard error 0.048, P＝0.3,5%CI 0.551~0.740). Multivariate Logistic regression analysis showed that the independent risk factors of AHF included MHR(OR 2.0,5%CI 1.141~5.743, P＝0.023), diabetes mellitus (DM) (OR 2.5,5%CI 1.012~4.977, P＝0.047), brain natriuretic peptide (BNP) (OR 5.8,5%CI 2.140~14.226, P＜0.001) and serum creatinine (OR 1.4,5%CI 1.001~1.026, P＝0.032). Conclusion MHR is an independent predictor of AHF during hospitalization in postmenopausal women with CHD.