- Background Decreased serum albumin level (SAL) was reported to be associated with increased risk of cardiovascular events and short term-mortality in patients with acute myocardial infarction (AMI). Objectives To evaluate the association between SAL and long-term mortality in AMI hospital survivors. Methods Retrospective analysis of patients admitted in a tertiary medical center for AMI 2002–2012 and discharged alive. Exclusion criteria: active infections, inflammatory diseases, significant liver or kidney failure, malignancy, ejection-fraction < 20%, severe heart valvular-disease and missing SAL. SAL was categorized as following: < 3.4, 3.4–3.7, 3.7–3.9, 3.9–4.1 and > 4.1 g/dL. The primary outcome was all-cause mortality for up-to 10-years post-AMI. Results Out of 12,535 patients, 8750 were included. Patients with reduced SAL were older, higher rate of women, increased prevalence of severe left ventricular dysfunction, chronic renal failure, diabetes mellitus and ST-elevation AMI, 3-vessel coronary artery disease, and in-hospital complications. While the prevalence of chronic ischemic coronary disease, dyslipidemia, smokers and obesity, was lower. Mortality rates throughout the follow-up period increased as SAL decreased with 17.6%, 24%, 28.5%, 38.6%, and 57.5% for SAL of > 4.1, 3.9–4.1, 3.7–3.9, 3.4–3.7 and < 3.4 g/dL respectively (p-for-trend < 0.001). Using the SAL category of > 4.1 g/dL as the reference group, Adjusted Hazard Ratio values were 1.14 (p = 0.107), 1.23 (p = 0.007), 1.39 (p < 0.001) and 1.70 (p < 0.001) for the SAL categories of 3.9–4.1, 3.7–3.9, 3.4–3.7 and < 3.4 g/dL respectively. Conclusions Decreased SAL on admission, including levels within “normal” clinical range, is significantly associated with long-term all-cause mortality in hospital survivors of AMI with a “dose–response” type association.