Direct percutaneous transluminal coronary angioplasty (PTCA) is a recognized alternative to intravenous thrombolytic therapy for early acute myocardial infarction (AMI). Fewer than one half of patients with AMI are candidates for thrombolytic therapy. We reviewed the records of 251 patients with the discharge diagnosis of AMI to determine the number of patients ineligible for thrombolysis who might be treatable with reperfusion methods other than intravenous thrombolysis. Forty percent of the patients (n = 101) were first seen within 6 hours and 51% (n = 128) were first seen within 12 hours of symptom onset. One third of the patients (n = 83) had no clear symptom at the time of initial examination. Exclusion criteria for intravenous thrombolysis were present in 187 of 251 patients (75%). Exclusion criteria for thrombolytic therapy included ECG ineligibility (n = 133), chest pain for more than 6 hours (n = 67), and age over 75 years (n = 64), comprising 79% of all exclusions. Of those first seen within 6 hours of symptom onset, 43 of 101 patients (43%) had an ineligible ECG, and 13 of 101 (13%) had age over 75 as exclusion criteria for thrombolysis. Forty-eight of 251 patients (19%) received intravenous thrombolysis. After early coronary angiography, intracoronary thrombolysis, direct PTCA, and emergency coronary artery bypass grafting were used in an additional 30 patients. The use of other forms of reperfusion therapy increased the number of patients treated early to 70 of 251 (28%) (p = 0.03). The use of a variety of forms of reperfusion therapy substantially increases the number of patients treated early compared with sole use of intravenous thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)