Few studies have investigated whether angiotensin II receptor blocker (ARB) is a practical alternative to angiotensin-converting enzyme inhibitor (ACEI) for long-term use after acute myocardial infarction (AMI) in real-world practice in the percutaneous coronary intervention (PCI) era. We compared 5-year survival benefits of ACEI and ARB in AMI patients registered with the Osaka Acute Coronary Insufficiency study. Study subjects were divided into 3 groups: ACEI (n=4,425), ARB (n=2,158), or patients without either drug (n=2,442). A total of 661 deaths were recorded. Cox regression analysis revealed that treatment with either ACEI or ARB was associated with reduced 5-year mortality (adjusted hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.58-0.83, p<0.001; and HR 0.79, 95% CI 0.64-0.98, p=0.03, respectively). However, Kaplan-Meier estimates and Cox regression analyses based on propensity score (PS) revealed that ACEI was associated with better survival than ARB from 2 to 5 years after survival discharge (adjusted HR 0.53, 95% CI 0.38-0.74, p<0.001). These findings were confirmed in a PS-matched population. In conclusion, treatment with ACEI was associated with better 5-year survival after AMI.