Interventional cardiologists have a variety of options when it comes to facilitated and direct percutaneous coronary intervention (PCI). Over the years, several controversies have surrounded the choices made before and during this process. Questions have been raised over the value of stenting all patients and the use of filters and thrombectomy devices. A number of important clinical trials have also investigated the efficacy of platelet glycoprotein IIb/IIIa inhibitors. Considerable interest is now taking place on how best to reduce reperfusion delays and to improve anticoagulation in the catheterization laboratory. Since direct PCI is often a slow process, better use of existing and future therapies, as well as advances in patient transport, are expected to improve patient outcomes.