For the management of ST-segment elevation acute myocardial infarction (STEMI), international guidelines recommend primary percutaneous coronary intervention with adjunctive antithrombotic therapy, the management of complications, and secondary prevention measures. Delivery of care has, however, lagged behind establishing the evidence for effectiveness. Approximately a quarter of all patients with STEMI still fail to receive reperfusion therapy. Additionally, for most patients delays substantially exceed guideline recommendations and secondary prevention is incomplete. What can be done? First, cardiologists need to take the lead in improving systems of care, with the integration of prehospital care within 'heart attack networks' involving intervention centers, nonintervention hospitals, primary care, and paramedic ambulance care. Several examples show that such systems are feasible. 'Door-to-balloon' initiatives can improve care in the final interventional hospital, but only make a modest contribution to total patient delay. Second, high-risk patients, including the elderly and those with cardiac complications like heart failure, should be targeted for more-aggressive interventional and pharmacologic therapy; the opposite situation currently exists in clinical practice (the treatment-risk paradox). Third, greater emphasis on quality improvement, collaboration among health professionals, and achieving high-quality care for all is required from funding bodies, regulatory agencies and professional societies.