Management of acute myocardial infarction in patients presenting with ST-segment elevation has evolved considerably over the past decades. In this review, we will limit the discussion to STEMI, and describe some recent developments and new insights into the evidence base of various therapeutic options. We will address the contemporary antithrombotic approach to treatment of this disorder. The controversy regarding optimal treatment of ACS, whether invasive or conservative, is discussed. This seems all the mandatory more as many study populations are not directly comparable, and some therapies are nowhere at hand. Progressively important cost-benefit considerations are another aspect that makes the assessment of the evidence claimed difficult.