Cardiac disease is a major cause of death in renal transplant recipients. One third of the cardiac deaths are attributed to acute myocardial infarction (AMI). Few data exist on predictors of long-term survival of renal transplant recipients after AMI. The purpose of this study is to determine predictors of survival (including treatment era) for renal transplant recipients in the United States after AMI. The US Renal Data System database of 783, 171 patients was used to retrospectively examine outcomes of renal transplant recipients hospitalized during 1977 to 1996 for a first AMI after initiation of renal replacement therapy. Long-term survival was estimated by life-table method, and independent predictors of survival were examined in a comorbidity-adjusted Cox model. There were 4,250 renal transplant recipients with AMI. The in-hospital death rate was 12.8%. Overall 2-year cardiac and all-cause mortality rates were 11.8% +/- 0.6% (SE) and 33.6% +/- 0. 8%, respectively. The poorest survival after AMI occurred in patients with diabetic end-stage renal disease (ESRD), with 2-year cardiac and all-cause mortality rates of 14.9% +/- 1.1% and 40.5% +/- 1.4%, respectively. In the Cox model, the risks for cardiac and all-cause death from AMI were 51% (P = 0.0003) and 45% less (P < 0. 0001) in 1990 to 1996 compared with 1977 to 1984, respectively. The long-term survival of renal transplant recipients in the United States after AMI has markedly improved in the modern treatment era. Patients with diabetic ESRD experience the worst outcome.