We reviewed 1,087 consecutive patients treated by primary coronary angioplasty for acute myocardial infarction; 309 were >or=75 and 778 were <75 years of age. Compared with the younger group, the older group had higher 30-day (8.1% vs 4.0%, p = 0.0057) and cardiac (6.5% vs 3.6%, p = 0.038) mortality rates. Successful reperfusion was achieved in the 2 groups at a similarly high rate (91.6% and 92.9%, p = 0.45). Successful compared with unsuccessful angioplasty decreased 30-day mortality rates in the older group (6.0% vs 30.8%, p <0.0001) and in the younger group (3.2% vs 14.5%, p <0.0001). When reperfusion was successful, the cardiac mortality rate in older patients was not significantly greater than that in younger patients (4.6% vs 2.8%, p = 0.14). By multivariate analysis in all 1,087 patients, overt cardiogenic shock on admission (odds ratio 44.7, 95% confidence interval 22.0 to 91.1, p <0.0001) and unsuccessful reperfusion (odds ratio 9.40, 95% confidence interval 4.11 to 21.5, p <0.0001) were found to be independent predictors of 30-day mortality, whereas age >or=75 years (odds ratio 1.79, 95% confidence interval 0.91 to 3.50, p = 0.090) was not. In conclusion, aggressive angioplasty in older patients improves prognosis.