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We aimed to study in-hospital mortality and long-term survival in elderly compared to younger patients with ST-segment elevation myocardial infarction (STEMI) in the era of primary angioplasty.This was a prospective cohort study. All consecutive STEMI-patients admitted to our hospital between September 2005-December 2011 were included in a local registry. Predefined variables were registered during hospital admission. Vital status was obtained from the Norwegian Cause of Death Registry with censoring date 31 December 2011. Adjusted effects of age ⩾80 years on in-hospital- and long-term mortality were determined using propensity score analysis. Of 4525 registered STEMI patients, 600 (13%) were octogenarians or older. In-hospital mortality was 17% in patients ⩾80 years and 4% in patients80 years. In invasively treated patients (83% of patients ⩾80 years; 98% of patients80 years), in-hospital mortality was 13% and 3.4%, respectively. Median follow-up time was 2.5 years. Three-year cumulative survival was 52% in patients ⩾80 years vs 89% in patients80 years. In invasively treated patients ⩾80 years, three-year survival was 58%. The adjusted odds ratio of in-hospital mortality was 2.61 (1.94-3.52) and adjusted incidence rate ratio of long-term mortality was 4.07 (3.43-4.84) in very elderly compared to younger patients.Short-term prognosis was acceptable in very elderly STEMI patients, especially in the invasively treated subgroup. However, only 52% of STEMI patients ⩾80 years were alive after three years of follow-up. Very elderly patients had 2.6 times higher risk of in-hospital mortality and 4.1 times the risk of not surviving during long-term follow-up compared to patients80 years, after adjustment for confounding factors and selection bias.