Aim To investigate the relationship between platelet-to-lymphocyte ratio (PLR) and myocardial reperfusion, in-hospital major adverse cardiac events (MACE) in patients with acute anterior myocardial infarction (MI) who underwent primary percutaneous coronary intervention (PPCI). Methods 136 consecutive patients with acute anterior MI who underwent PPCI were enrolled in this retrospective study. The quartile of PLR before the procedure was obtained by quadratic method. Patients having values in the fourth quintile group was defined as the high PLR group ( PLR≥165), and those having values in the lower 3 quintiles were defined as the low PLR group (PLR<165). Baseline clinical features, Killip classification, thrombolysis in myocardial infarction (TIMI) flow grade, myocardial blush grade (MBG) and in-hospital MACE were analyzed. Results Patients with high PLR had higher Killip grade compared with patients with low PLR (47% vs 20%, P=0.005). Patients in the high PLR group had significant lower TIMI flow (36% vs 14%, P=0.004) and MBG grade (44% vs 21%, P=0.016) than those in the low PLR group. More patients with high PLR had impaired myocardial perfusion than those with low PLR (56% vs 27%, P=0.002). Multivariate analyses indicated that the independent risk factors of impaired myocardial perfusion were PLR (OR 1.9,5% CI 1.004～1.015, P=0.001), thrombus aspiration (OR 1.3,5% CI 1.012～2.144, P=0.043), BNP (OR 1.1,5% CI 1.000～1.002, P=0.034) and CK-MB peak (OR 1.2,5% CI 1.001～1.005, P=0.067). Furthermore, the high PLR group had significantly higher MACE (25% vs 7%, P=0.004) and all-cause mortality (14% vs 2%, P=0.014) than the low PLR group. Conclusion The study suggested that PLR was an independent risk factor of impaired myocardial perfusion. Moreover, higher PLR is related to all-cause death and in-hospital MACE in patients with anterior MI who underwent PPCI.