Conflicting evidence exists regarding gender differences in the management and outcomes of myocardial infarctions (MIs). In this study, it was hypothesized that the management and outcomes of MIs would not differ by gender after proper adjustment for age, access to care, MI characteristics, and co-morbidities. Data from a published MI validation study, which sampled 2,200 MI hospitalizations in Medicare beneficiaries with the prescription drug benefit for detailed hospital chart review, were used. Gender differences in the use of MI-related procedures and recommended cardiovascular medications as well as short- and long-term mortality were assessed using multivariate regression. A total of 1,625 patients were identified (80% women) with confirmed MIs for whom complete clinical information was available. Compared with men, women were older and had higher body mass index. Women were more likely to have diabetes, renal dysfunction, and depression, but less likely to have had previous MIs, chronic lung disease, cancer, and to use tobacco. The characteristics of the index MIs were similar, except for non-Q-wave MIs being more common in men. The management of the MIs during admission was similar. During follow-up of up to 6.6 years, men were 40% more likely to die than women (95% confidence interval 21% to 62%), but no mortality difference was observed in patients aged 65 to 74 years (hazard ratio 0.92, 95% confidence interval 0.62 to 1.36), whereas in those aged > or =75 years, men were more likely to die than women (hazard ratio 1.54, 95% confidence interval 1.30 to 1.82). In conclusion, for older patients, the management of MIs did not significantly differ between men and women. Men, especially those aged > or =75 years, however, had worse short- and long-term prognoses compared with women of a similar age. The mortality was highest and the gender effect was more pronounced during the MI hospitalizations.