Objective To investigate the predictive value of myocardial contrast echocardiography (MCE) combined with real-time three-dimensional echocardiography (RT-3DE) for major adverse cardiovascular events (MACE) in elderly patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). Methods A total of 95 elderly patients with AMI who underwent PCI in People"s Hospital of Yangjiang, Guangdong Medical University from January 2020 to December 2023 were reviewed. They were divided into MACE group (31 cases) and non-MACE group (64 cases) according to the presence or absence of MACE. Clinical data, MCE and RT-3DE parameters of the two groups were compared. Multivariate logistic regression analysis was conducted to identify the predictors for the occurrence of MACE in elderly patients with myocardial infarction after PCI. The performance of MCE and RT-3DE parameters in predicting the occurrence of MACE after PCI was evaluated using the receiver operating characteristic (ROC) curve. Results Myocardial blood flow (A.β) value, left ventricular ejection fraction (LVEF) and peak ejection rate (PER) in the MACE group were significantly lower than those in the non-MACE group, and left ventricular end systolic volume (LVESV) was significantly larger than that in the non-MACE group (P<0.05). Logistic regression analysis found that A.β, LVEF, PER and LVESV were predictive factors for MACE after PCI (P<0.05). ROC curve analysis results showed that the AUC values of A.β, LVEF, PER and LVESV for predicting MACE after PCI were 0.768, 0.675, 0.792 and 0.786. The AUC of joint prediction with the three was 0.931, significantly larger than that of each parameter (Z＝5.470、3.028、5.963、5.315,P＝<0.01、0.003、<0.01、<0.01). The sensitivity and specificity of joint prediction were 90.32% and 85.94%. Conclusion MCE and RT-3DE can be used to evaluate myocardial perfusion and left ventricular function in elderly patients with AMI after PCI. Combination of the two can be used to predict the occurrence of MACE after PCI.