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• Among 2012 STEMI patients, 185 patients (9%) had no SMuRFs. • SMuRF-less patients did not differ in infarct severity as assessed by CMR imaging. • Clinical outcomes (MACE) were comparable between patients with and without SMuRFs. Standard modifiable cardiovascular risk factors (SMuRFs) are well-established players in the pathogenesis of ST-elevation myocardial infarction (STEMI). However, in a significant proportion of STEMI patients, no SMuRFs can be identified, and the outcomes of this subgroup are not well described. To assess the infarct characteristics at myocardial-tissue level and subsequent clinical outcomes in SMuRF-less STEMIs. This multicenter, individual patient-data analysis included 2012 STEMI patients enrolled in four cardiac magnetic resonance (CMR) imaging studies conducted in Austria, Germany, Scotland, and the Netherlands. Unstable patients at time of CMR (e.g. cardiogenic shock/after cardiac arrest) were excluded. SMuRF-less was defined as absence of hypertension, smoking, hypercholesterolemia, and diabetes mellitus. All patients underwent CMR 3(interquartile range [IQR]:2–4) days after infarction to assess left ventricular (LV) volumes and ejection fraction, infarct size and microvascular obstruction (MVO). Clinical endpoints were defined as major adverse cardiovascular events (MACE), including all-cause mortality, re-infarction and heart failure. No SMuRF was identified in 185 patients (9%). These SMuRF-less patients were older, more often male, had lower TIMI risk score and pre-interventional TIMI flow, and less frequently multivessel-disease. SMuRF-less patients did not show significant differences in CMR markers compared to patients with SMuRFs (all p > 0.10). During a median follow-up of 12 (IQR:12-27) months, 199 patients (10%) experienced a MACE. No significant difference in MACE rates was observed between SMuRF-less patients and patients with SMuRFs (8vs.10%, p = 0.39). In this large individual patient-data pooled analysis of low-risk STEMI patients, infarct characteristics and clinical outcomes were not different according to SMuRF status. This graphical abstract summarizes the main results of the current study. Of a total of 2012 ST-elevation myocardial infarction (STEMI) patients, 9% presented without standard modifiable cardiovascular risk factors (SMuRF). SMuRF-less status was associated with age, male sex, thrombolysis in myocardial infarction (TIMI)-risk score, multivessel disease, and TIMI-flow pre-percutaneous coronary intervention (PCI). No significant differences in infarct size, microvascular obstruction (MVO), and left ventricular ejection fraction (LVEF) could be detected by cardiac magnetic resonance (CMR), ultimately showing no significant differences in outcome. "Created with Biorender" [Display omitted] [ABSTRACT FROM AUTHOR]