- Thrombolytic therapy in acute myocardial infarction reduces infarct size and prolongs survival. Coronary reperfusion can also be achieved by direct (primary) percutaneous transluminal coronary angioplasty (PTCA). Whereas thrombolysis has the benefits of simplicity and ease of administration, PTCA achieves high reperfusion rates at a relatively low risk of bleeding and is less frequently contraindicated. These two strategies were evaluated in randomized trials as well as in a number of large registries. In most of the randomized trials, PTCA was found to yield better results than thrombolysis, although the largest randomized trial found only a modest and transient benefit. The registries, on the other hand, found no difference between the two treatment strategies. We analyze the available data and discuss the possible causes for the discrepant results in different studies. PTCA seems to be a better strategy to open occluded coronary arteries, but its clinical benefit is critically dependent on operator experience and on the time to treatment. It is the treatment of choice if the culprit lesion can be crossed within 1 hour of presentation. Home thrombolysis offers the chance of very early reperfusion and may be the most cost-effective way of improving the overall results of reperfusion therapy in the community. Coronary stenting and more effective platelet inhibition may improve the results of medical and interventional reperfusion, and further comparisons of these two strategies will be required.