Background: Both paclitaxel-eluting stents (PES) and sirolimus-eluting stents (SES) have reduced the risk of restenosis, particularly in high-risk patients and lesion subsets. However, their comparative performance in patients with metabolic syndrome (MS) patients with acute ST-elevation myocardial infarction (STEMI) is not known. The aim of this study was to compare the safety and efficacy of PES and SES for treatment of acute STEMI patients with MS. Methods: By employing data from Korea Acute Myocardial Infarction Registry (KAMIR; from November 2005 to December 2007), a total of 1,536 MS patients suffered from acute STEMI who underwent primary percutaneous coronary intervention (PCI) were enrolled: The SES (Cypher, Cordis, Johnson & Johnson, New Brunswick, New Jersey) deployment group were 906 and PES (Taxus, Boston Scientific, Natick, Massachusetts) deployment group were 630. The primary end point was major adverse cardiac events (MACE: cardiac death, non-cardiac death, re-myocardial infarction, re-PCI and coronary artery bypass surgery) during one-year follow-up. Results: At 1 year the incidence of cardiac death was 1.3% in the SES and 3.7% in the PES group (p = 0.023) and the incidence of composite MACE was 10.6% in the SES and 16.0% in the PES group (p = 0.017), but the rate of re-PCI was 8.1% in the SES and 10.9% in the PES group (p = 0.152). Six patients in the SES group (0.7%) and 2 patients in the PES group (0.3%) experienced definite stent thrombosis (p = 0.48). Multivariate analysis using Cox regression for 1 year composite MACE showed no significant difference between two groups (relative risk = 1.313, 95% confidence interval = 0.762-2.263, p = 0.326). Conclusions: The data generated from the KAMIR revealed that implantation of both SES and PES in MS patients with acute STEMI provided comparable clinical and angiographic outcomes.