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Background Differences in the predictors between ventricular septal rupture (VSR) and free wall rupture (FWR) have not been fully studied. Data on the prevalence and clinical outcome of heart rupture are limited. Hypothesis This study aimed to investigate heart rupture incidence and clinical results in patients with acute myocardial infarction (AMI). Methods Of 9265 AMI patients in the MOODY registry between March 1999 and October 2016, a total of 146 were studied. The primary clinical endpoint was rupture prevalence and in-hospital mortality. Independent factors of heart rupture were analyzed using Cox proportional model and were compared between patients with VSR and those with FWR. Results Of 9265 AMI patients, 146 (1.58%) patients had a heart rupture (FWR, 94 (1.02%)) and VSR (52 (0.56%)). All patients with FWR died during hospitalization, and in-hospital mortality was recorded in 37 (71.2%) patients with VSR, who had an extremely longer time delay from AMI onset to the first medical contact (FMC) (~20 h). FWR usually occurred in patients with ST-elevation myocardial infarction (STEMI) patients with a FMC ≥ 3 h, for whom primary reperfusion was not performed. Percutaneous repair at 1–2 weeks following AMI was associated with less mortality, and 9 of 38 patients who underwent non-primary reperfusion died post procedure. Conclusion This study demonstrated the importance of shortening FMC to prevent VSR and of early primary reperfusion in STEMI patients to reduce FWR. Urgent closure of rupture is necessary to reduce in-hospital and 1-year mortality. Clinical trial registration http://www.clinicaltrials.org , identifier: No. NCT03051048.