Aim <p>To evaluate the prognostic value of dynamic single-photon emission computed tomography (SPECT) in patients with early acute myocardial infarction (AMI).</p> Methods <p>Sixty-three patients with a first AMI were enrolled. Diagnostic and treatment algorithms were completed in full accordance with standard medical care. Dynamic cadmium-zinc-telluride (CZT) SPECT was performed 7–10 days after AMI. Stress and rest myocardial blood flow (MBF), myocardial flow reserve (MFR), summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS) were evaluated. Based on the occurrence of major adverse cardiac events (MACE) during a three-year follow-up, patients were divided into two groups: (1) MACE– (<i>n</i> = 53) and (2) MACE+ (<i>n</i> = 10).</p> Results <p>Patients with MACE were characterized by a higher risk according to the GRACE Scale (<i>p</i> = 0.03) and a more severe condition by the Killip classification (<i>p</i> = 0.001). Dynamic SPECT revealed significantly lower rest MBF in the MACE + group compared to the MACE– group: 0.35 (0.32; 0.45) mL/min/g vs. 0.59 (0.32; 0.81) mL/min/g, respectively (p-value should be added here). Multivariable analysis demonstrated that rest MBF (OR 0.375; 95% CI: 0.15–0.95) and Killip class (OR 7.67; 95% CI: 1.65–35.54) were independent predictors of MACE in patients with a first acute myocardial infarction. A rest MBF value ≤ 0.39 mL/min/g predicted MACE within 3 years with a sensitivity of 70.0% and a specificity of 69.8%.</p> Conclusion <p>Dynamic SPECT may have long-term prognostic value for patients with acute myocardial infarction. Rest MBF is a promising additional predictor of MACE when combined with Killip. Further research and multicenter studies are needed to confirm the role of dynamic SPECT.</p> <p>Clinical trial registration: none.</p> Graphical abstract <p></p>