Background—Abnormal heart rate turbulence (HRT) is associated with an increased risk of mortality in the chronic phase of myocardial infarction (MI) in the prethrombolytic and thrombolytic eras. However, the impact of direct percutaneous coronary intervention (PCI) on HRT in the acute phase of MI and its association to the epicardial infarct-related arterial flow has not been examined.Methods and Results—We investigated HRT in 126 patients undergoing direct PCI for a first MI. Turbulence onset and turbulence slope were determined before reperfusion, during the initial 2 hours after reperfusion, and during hours 6 to 24 after reperfusion. HRT significantly improved after PCI. There were no significant differences in baseline clinical characteristics between Thrombolysis in Myocardial Infarction Trial classification (TIMI) 2 (n=28) and TIMI 3 (n=98) flow. After PCI, turbulence slope increased (13.2±11 to 18.1±12 ms/beat,P<0.001) and turbulence onset decreased (−0.008±0.04% to −0.023±0.04%,P<0.01) in patients with TIMI 3 flow after PCI, whereas there were no significant alterations of turbulence slope (12.2±10 to 12.8±6.5 ms/beat) and turbulence onset (−0.009±0.05% to −0.003±0.03%) in patients with TIMI 2 flow.Conclusions—The improvement of HRT after successful reperfusion is a previously unreported effect of direct PCI for acute MI, reflecting rapid restoration of baroreceptor response. The persistent impairment of HRT after PCI in patients with TIMI 2 flow indicates a sustained blunted baroreflex response and may reflect a more severe microvascular dysfunction.