Management of myocardial infarction evolved because of understanding of underlying disease processes and clinical trials of “chemical” and “mechanical” clot dissolution that reduced in-hospital mortality. Meta-analysis comparing these treatment strategies marginally favours angioplasty. Current European Society of Cardiology guidelines propose primary angioplasty as the preferred therapeutic option but few units in the UK can offer angioplasty on demand as a designated “heart attack centre”. Thrombolysis will continue as it is widely available and training needs and costs less than angioplasty. Community thrombolysis should be made available for those patients who do not wish for such aggressive intervention or as a prelude to transfer time to a heart attack centre distant from a triage hospital.