Coronary reperfusion for acute ST-elevation myocardial infarction can be accomplished with fibrinolytic therapy or with percutaneous coronary intervention (PCI). Primary PCI provides more effective and sustained early reperfusion than fibrinolytic therapy, but is only available in a minority of hospitals worldwide. There is a lack of a definite method for identification of patients who have inadequate reperfusion after fibrinolysis. Transfer of patients after fibrinolysis for diagnostic angiography and possible rescue therapy is safe and feasible. Rescue PCI with the use of stents and antiplatelet therapy decreases cardiovascular mortality and morbidity compared with conservative therapy. Increasing use of primary PCI and forming networks to transfer patients to centers that offer primary PCI may decrease the need for rescue therapy in the future.