Objective To construct a predictive model for adverse ventricular remodeling in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing emergency percutaneous coronary intervention (PCI) based on angiography-derived microcirculatory resistance(AMR) and lipid variability. Methods A retrospective analysis was conducted on 312 patients with acute STEMI who underwent emergency PCI from The First Affiliated Hospital of Bengbu Medical University January 2022 to January 2024. Clinical data were collected preoperatively and at 6 months postoperatively. Patients were divided into two groups based on the occurrence of ventricular remodeling: the ventricular remodeling group (n=87) and the non-ventricular remodeling group (n=225). Baseline indices and lipid variability indices were compared between the two groups. A predictive model was constructed using the aforementioned indices and its clinical value was analyzed. Results Significant differences were observed in age, total ischemic time, culprit vessel, and AMR、Postoperative electrocardiogram ST segment drop of more than 50% between the non-ventricular remodeling group and the ventricular remodeling group (P＜0.05). Lasso regression analysis identified 10 factors to be included in the logistic regression analysis. Logistic regression analysis indicated that AMR, LDL-SD, LDL-CV, LDL-VIM, HDL-SD, HDL-CV, HDL-VIM, LP(a)-SD, LP(a)-CV, and LP(a)-VIM are risk factors affecting the occurrence of adverse ventricular remodeling in patients with acute STEMI undergoing emergency PCI (P＜0.05). A model was constructed using the 10 risk factors selected by multivariate logistic regression analysis. Internal validation was performed using the Bootstrap resampling method. The results showed that the predictive model had an index C of 0.771 and an ROC of 0.771, with good fit between the original curve and the corrected curve, indicating good predictive performance of the model. Conclusion AMR and lipid variability are associated with the occurrence of adverse ventricular remodeling in patients with acute STEMI undergoing emergency PCI. The predictive model constructed based on AMR and lipid variability has high predictive value for adverse ventricular remodeling in patients with acute STEMI undergoing emergency PCI