A retrospective study analyzed 2467 patients aged ≥75 years with acute myocardial infarction (AMI), with mechanical complications occurring in 9.6% of patients. The most common complication was ventricular aneurysm (92.8% of cases), which was strongly associated with anterior infarctions (71.2%) and reperfusion therapy (81.7%). Complications associated with ruptures occurred more often in non-reperfused heart attacks. Patients with mechanical complications had lower systolic blood pressure, higher prevalence of STEMI, more severe inflammatory status (higher neutrophil and hs-CRP values) and more significant myocardial damage (higher cTnT, NT-proBNP). Multivariable analysis identified Killip class III/IV (OR = 2.99), increased neutrophil percentage (OR = 1.05), hyperkalemia (OR = 1.70), and hypoalbuminemia (OR = 0.92) as independent risk factors. Paradoxically, a history of hypertension was associated with a lower risk of mechanical complications (OR = 0.50). These results suggest a specific risk profile of mechanical complications in very elderly patients with AMI.