Background Few data exist on the optimal revascularization management in patients with acute myocardial infarction (AMI) complicated with decompensated heart failure and accompanied by multivessel diseases. Methods We retrospectively analyzed 5694 patients who underwent percutaneous coronary intervention with the use of drug eluting stent in COnvergent REgistry of cAtholic and chonnAm university for AMI (COREA-AMI) from January 2004 to December 2009. Primary observational end-point was a composite of all-cause death, nonfatal myocardial infarction(MI), or any revascularization during followup period. Results Of 5694 AMI patients, 405 patients who had multivessel diseases and were complicated with decompensted heart failure were enrolled. 221 patients were treated with culprit-only revascularization (COR group), and 184 patients with multivessel revascularization (MVR group) Median follow up was 11 months (interquatile range: 2.7 to 19.3). MVR was associated with significantly reduced incidences of mortality (MVR 22.3% vs COR 40.3%, p<0.001) and a composite of primary outcome during follow up period (MVR 32.6% vs COR 47.1%, p=0.003). However, after adjusting covariates such as age, the presence of left main disease, chronic kidney disease and ST-segment elevation MI using multivariable Cox analysis, MVR and COR groups showed similar clinical outcome (adjusted hazard ratio 0.84, 95% confidence interval 0.66 to 1.71, p=0.634) Conclusion In patients with AMI who were complicated with decompensated heart failure and had multivessel disease, a strategy of culprit-only revascularization is as effective as multivessel revascularization