Despite the advancements in reperfusion therapy, elderly patients with acute myocardial infarction (AMI) continue to have higher mortality and complication rates than younger patients. To evaluate this group we reviewed 994 consecutive patients with AMI at our hospital during a 24-month period. There were 307 patients aged > 75 years and 687 younger patients. Demographic analysis of the 2 groups showed that the elderly had a higher proportion of women (56% vs 31%, p < 0.01), more previous AMI (32% vs 23%, p < 0.01), and a higher incidence of bundle branch block (18% vs 8%, p < 0.01). Only 8% of the elderly and 36% of the younger patients were considered eligible for thrombolysis (p < 0.01). In the elderly, risk of bleeding and late presentation were the most common reasons for exclusion from treatment with thrombolytic therapy. Despite a higher proportion of non-Q-wave AMI (56% vs 44%, p < 0.01) in the elderly, the incidence of congestive heart failure (47% vs 23%, p < 0.001) and death (28% vs 11%, p = 0.001) was greater. Causes of death were not significantly different. Increased mortality in the elderly was not due to multisystem failure but to impaired myocardial reserve, suggesting that more aggressive reperfusion strategies may improve prognosis.