ABSTRACT Background: Primary percutaneous coronary intervention (PPCI) is the optimal reperfusion method for ST-elevation myocardial infarction (STEMI). When compared to thrombolysis alone, another mechanism of transfer—referred to as pharmaco-invasive PCI—for prompt angioplasty following thrombolytic therapy is necessary. Objective: This study compared primary PCI with pharmacoinvasive PCI for patients admitted with acute anterior STEMI in order to evaluate the short-term recovery of left ventricular systolic and diastolic performance. Subjects and methods: From June 2020 to June 2022, we enrolled 100 patients with anterior STEMI who were admitted to Zagazig University Hospital in Egypt. In two groups of fifty patients each, the patients were assigned. The first group received primary PCI, while the second group underwent pharmacoinvasive PCI within 24 hours after presentation. Three months of follow-up on both groups were used to evaluate the systolic and diastolic myocardial recovery. Ejection fraction (EF) and global longitudinal strain (GLS) were used to evaluate systolic function. Tissue Doppler E/e' ratio was used for assessment of diastolic function. The E/(e'xs') index, a special Doppler measure that considers both systolic and diastolic functions, was also evaluated. Results: In the pharmacoinvasive group, the time from pain to ECG was considerably shorter (p = 0.02). The PPCI group had statistically greater average ST segment elevation and resolution (p= 0.03 and 0.02, respectively). The majority of patients in both groups had MBG 3, and the pharmacoinvasive group had a statistically significantly greater prevalence of establishing MBG 3 (p = 0.02). While there was no statistically significant difference between the two groups for the ejection fraction after revascularization, there was a statistically significant difference between them for the GLS, E/e' ratio, and E/(e'x s') ratio, with P values of 0.02 to 0.003 and 0.004 respectively. The EF and GLS both improved three months after revascularization, and there was a statistically significant difference between the two groups with P values of 0.03 for the GLS, 0.001 for the (E/e'x s' ) ratio, and 0.001 for the E/e' ratio, respectively. The most effective predictors of MACE, according to multivariate regression analysis, were GLS immediately following revascularization and both E/(e'x s') ratio immediately and 3 months after revascularization. E/(e's') at discharge had a cut-off value of 1.72 (78% sensitivity and 70% specificity), which was the best indicator of MACE. The most effective predictors of MACE, according to multivariate regression analysis, were GLS immediately following revascularization and both E/(e'x s') ratio immediately and 3 months after revascularization. E/(e's') at discharge had a cut-off value of 1.72 (78% sensitivity and 70% specificity), which was the best indicator of MACE. Conclusions: This study demonstrated that when primary PCI is unavailable or cannot be performed promptly in accordance with the recommendations of the guidelines, pharmaco-invasive PCI within 24 hours of fibrinolysis constitutes a reliable reperfusion approach for patients presenting with anterior STEMI. We also concluded that that pharmaco-invasive strategy could offer a superior outcome regarding microvascular circulation reflected in better myocardial blushing and better short-term recovery of the diastolic function. Evaluation of GLS and E/(e`xs`) ratio before discharge has a prognostic impact regarding short-term systo-diastolic myocardial recovery.