Direct percutaneous transluminal coronary angioplasty (PTCA) was performed as the primary means of establishing reperfusion during acute myocardial infarction in 105 elderly patients (mean age +/- standard deviation 75 +/- 4 years) at a mean of 5.5 +/- 4.0 hours from symptom onset. Fifty-two patients (50%) had anterior infarctions, 70 (67%) had significant narrowing in greater than 1 vessel, and 12 (11%) were in cardiogenic shock. Primary success was achieved in 91% of the infarct-related arteries. Four patients with failed PTCA underwent emergency bypass surgery; 10 had early symptomatic reocclusion of the dilated vessel. There was 1 death acutely in the catheterization laboratory. The overall in-hospital mortality was 18%. Three-vessel coronary artery disease and cardiogenic shock on presentation were the strongest predictors of in-hospital death. Global ejection fraction improved from 54 +/- 13 to 61 +/- 15% (p less than 0.001). The 1- and 5-year survival rates, including in-hospital deaths, were 73 and 67%, respectively. It is concluded that direct PTCA is an effective means of salvaging ischemic myocardium during acute myocardial infarction in the elderly patient. It is associated with a high success rate and low complication rate. The short- and long-term survival in this high-risk group of patients are improved compared with survival rates in historical controls.