This manuscript is focused around two key messages from the current Guidelines of the European Society of Cardiology on ST elevation myocardial infarction; the need to use primary angioplasty whenever timely and effectively applicable and the importance of organisational changes in the emergency system to implement this indication. Based on a review of the trials motivating these guidelines and the successful experience of many European countries, practical indications are provided on the methods to overcome resistances and malpractices that prevent the delivery of optimal care in these critically ill patients.