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Background: To assess the relationship between glycemic variability, glucose fluctuation trajectory and the risk of in-hospital mortality in patients with acute myocardial infarction (AMI). Methods: This retrospective cohort study included AMI patients from eICU Collaborative Research Database. In-hospital mortality of AMI patients was primary endpoint. Blood glucose levels at admission, glycemic variability, and glucose fluctuation trajectory were three main study variables. Blood glucose levels at admission were stratified into: normal, intermediate, and high. Glycemic variability was evaluated using the coefficient of variation (CV), divided into four groups based on quartiles: quartile 1: CV≤10; quartile 2: 1030. Univariate and multivariate Cox regression models to assess the relationship between blood glucose levels at admission, glycemic variability, glucose fluctuation trajectory, and in-hospital mortality in patients with AMI. Results: 2590 participants were eventually included in this study. There was a positive relationship between high blood glucose level at admission and in-hospital mortality [hazard ratio (HR) = 1.42, 95%confidence interval (CI): 1.06–1.89]. The fourth quartile (CV>30) of CV was associated with increased in-hospital mortality (HR = 2.06, 95% CI: 1.25–3.40). The findings indicated that only AMI individuals in the fourth quartile of glycemic variability, exhibited an elevated in-hospital mortality among those with normal blood glucose levels at admission (HR = 2.33, 95% CI: 1.11–4.87). Additionally, elevated blood glucose level was a risk factor for in-hospital mortality in AMI patients. Conclusion: Glycemic variability was correlated with in-hospital mortality, particularly among AMI patients who had normal blood glucose levels at admission. Our study findings also suggest early intervention should be implemented to normalize high blood glucose levels at admission of AMI. [ABSTRACT FROM AUTHOR]