After successful cardiopulmonary resuscitation, acute ST-elevation myocardial infarction (STEMI) may be documented. We investigated the incidence and prognosis of patients admitted to our department between 1 January 2000 and 31 December 2004. Among 2393 consecutive patients with STEMI, 135 (5.7%) presented after a return of spontaneous circulation (ROSC). Forty-nine patients (36%) regained consciousness and 86 patients (64%) remained unconscious during initial evaluation. The delay from collapse to advanced cardiac life support (ACLS) was longer in comatose patients (5.8 min versus 0.5 min; p<0.01) in those with a lower proportion of shockable rhythm (76% versus 96%; p<0.01) and in those with a less favourable course of ACLS were also documented. Primary percutaneous coronary intervention (PCI) was performed in all but one conscious patient with success rate (96% versus 94%; p=0.63) and hospital survival without neurological deficit (100% versus 94.8%; p=0.20) comparable to patients without cardiac arrest. In comatose patients, primary PCI was performed in 79% with a somewhat lower success rate (82%, p=0.21). Mechanical ventilation, haemodynamic support, haemodialysis and antimicrobial agents were used more frequently in comatose patients. Hospital survival among comatose patients was 51% and hospital survival with cerebral performance category (CPC) 1 or 2 was 29%. Accordingly, outcome of patients with STEMI who regain consciousness after ROSC and undergo primary PCI is comparable to patients without cardiac arrest. This is in contrast with comatose survivors who, despite aggressive reperfusion treatment, had a significantly worse outcome.