['To compare long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI) using radial and femoral arterial access.', 'The present study was an observational cohort study of patients with STEMI treated consecutively with PPCI between 2004 and 2011 at a single centre. The primary end point was all-cause mortality at a median follow-up of 3 years.Among 2727 patients, 1600 (58.7%) underwent PPCI via the femoral route. The femoral group was older (64.7 vs. 61.7 years; P\u200a<\u200a0.0001), and had higher rates of diabetes (18.6% vs. 16.0%; P\u200a<\u200a0.0001), previous PCI (11.2 vs. 7.8%; P\u200a=\u200a0.004), previous myocardial infarction (15.3 vs. 8.3%; P\u200a<\u200a0.0001) and cardiogenic shock (9.8 vs. 1.3%; P\u200a<\u200a0.0001). Bleeding complications were more frequent in the femoral group (4.7 vs. 1.2%; P\u200a<\u200a0.0001). The 5-year death rate was significantly higher in the femoral group than in the radial group (10.4 vs. 3.0%; P\u200a<\u200a0.0001). After adjustment for confounding variables, bleeding complications [heart rate 2.07 (95% confidence interval 1.05-4.08)] and femoral access [heart rate 1.60 (95% confidence interval 1.02-2.53)] were independent predictors of all-cause mortality. After stratification using the propensity score, excess long-term mortality in patients treated via the femoral approach was predominantly in patients with a high baseline risk of death.'] Is radial primary percutaneous coronary intervention independently associated with decreased long-term mortality in high-risk ST-elevation myocardial infarction patients?