Background: The DANAMI-2 trial showed that in patients with ST-elevation myocardial infarction (STEMI), a strategy of inter-hospital transfer for primary angioplasty was superior to on-site fibrinolysis at 30 days follow-up. This paper reports on the pre-specified long-term composite endpoint at 3 years follow-up in DANAMI-2. Methods and results: We randomized 1572 patients with STEMI to primary angioplasty or intravenous alteplase; 1129 patients were enrolled at 24 referral hospitals and 443 patients at 5 angioplasty centres. Ninety-six percent of inter-hospital transfers for angioplasty were completed within 2 h. No patients were lost to follow-up. The composite endpoint (death, clinical re-infarction, or disabling stroke) was reduced by angioplasty when compared with fibrinolysis at 3 years (19.6 vs. 25.2%, P =0.006). For patients transferred to angioplasty compared with those receiving on-site fibrinolysis, the composite endpoint occurred in 20.1 vs. 26.7% (P = 0.007), death in 13.6 vs. 16.4% (P = 0.18), clinical re-infarction in 8.9 vs. 12.3% (P = 0.05), and disabling stroke in 3.2 vs. 4.7% (P = 0.23). Conclusion: The benefit of transfer for primary angioplasty based on the composite endpoint was sustained after 3 years. For patients with characteristics as those in DANAMI-2, primary angioplasty should be the preferred treatment strategy when inter-hospital transfer can be completed within 2 h.