Major advances have been made in primary reperfusion and adjunctive therapies for STEMI. Mechanical reperfusion therapy has become the preferred reperfusion strategy for patients with STEMI. Outcomes have improved with the use of stents, platelet inhibitors, and with increased experience, and there is a promise that outcomes can become even better with new methods to enhance myocardial reperfusion and reduce reperfusion injury and with new anticoagulants and drug-eluting stents. Recent trends from the NRMI have shown that the frequency of use of primary PCI has increased and has surpassed lytic therapy, but primary PCI is used to treat only a minority of patients with STEMI. The major challenge for clinicians in the next decade will be to find new ways to make mechanical reperfusion more available, improve outcomes through the use of optimal adjuvant therapies and improved systems of care to speed primary PCI. The nation-wide effort to reduce door-to-balloon times has been launched by American Heart Association, with goal of making primary PCI more available to patients with STEMI.