BACKGROUND The primary objective of reperfusion therapies for acute myocardial infarction is not only restoration of blood flow in the epicardial coronary artery but also complete and sustained reperfusion of the infarcted part of the myocardium. METHODS We studied 777 patients who underwent primary coronary angioplasty during a six-year period and investigated the value of angiographic evidence of myocardial reperfusion (myocardial blush grade) in relation to the extent of ST-segment elevation resolution, enzymatic infarct size, left ventricular function, and long-term mortality. The myocardial blush immediately after the angioplasty procedure was graded by two experienced investigators, who were otherwise blinded to all clinical data: 0: no myocardial blush, 1: minimal myocardial blush, 2: moderate myocardial blush, and 3: normal myocardial blush. RESULTS The myocardial blush was related to the extent of the early ST-segment elevation resolution on the 12-lead electrocardiogram. Patients with blush grades 3, 2 and 0/1 had enzymatic infarct sizes of 757, 1143 and 1623 (p<0.0001), respectively, and ejection fractions of 0.50, 0.46 and 0.39, respectively (p<0.0001). After a mean±SD follow-up of 1.9±1.7 years, mortality rates of patients with myocardial blush grades 3, 2 and 0/1 were 3%, 6% and 23% (p<0.0001), respectively. Multivariate analysis showed that the myocardial blush grade was a predictor of long-term mortality, independent of Killip class, Thrombolysis In Myocardial Infarction (TIMI) grade flow, left ventricular ejection fraction, and other clinical variables. CONCLUSIONS In patients after reperfusion therapy, the myocardial blush grade as seen on the coronary angiogram can be used to describe the effectiveness of myocardial reperfusion, and is an independent predictor of long-term mortality.