The effect of gender and other clinical variables on short-term and long-term cardiac mortality after a first transmural myocardial infarction (MI) was assessed in a population-based hospital register. A cohort of 1216 consecutive patients (1023 men and 193 women), 25-74 years old admitted to the only reference hospital with a coronary care unit at Girona, Northeastern Spain, were recruited for 1978 to 1988 and followed-up for a mean period of almost 5 years (3-12 years). Compared with men, women had a relative risk (RR) of 1.56 (95% confidence interval (CI) of 0.99-2.48) of dying in the acute phase of MI after adjusting for age, MI location, presence of severe arrhythmias, diabetes and hypertension. However, when additionally adjusting for severity (Killip class), women presented a RR of 1.11. Age and hypertension were independent risk factors for acute mortality. Women surviving the acute period of MI showed a RR of 1.37 (CI 0.97-1.92) for long-term mortality, that was only slightly modified by Killip class during hospital stay (RR = 1.27). Age and diabetes were independent risk factors for long term mortality. It is concluded that women have a 56% excess risk for early mortality after a first transmural MI than men mainly explained by a higher severity.