Reperfusion therapy is a critical part of the emergency treatment of acute myocardial infarction, and its use has resulted in a dramatic reduction in both the morbidity and mortality of myocardial infarction over the past 20 years. Nonetheless, reperfusion therapy is markedly underutilized, particularly in subsets of patients at higher risk such as the elderly. A choice now exists between the use of intravenous fibrinolytic therapy or primary percutaneous coronary intervention (PCI) for reperfusion therapy. However, because primary PCI is not available at most hospitals, fibrinolytic therapy remains the mainstay of coronary reperfusion therapy in most countries around the world. Prompt use of fibrinolytic therapy is associated with a marked reduction in mortality and reduces left ventricular failure and subsequent congestive heart failure. Hesitancy with the use of fibrinolytic therapy comes from a lack of a clear understanding of the appropriate guidelines for its utilization and a lack of knowledge of which patients are appropriate, the bleeding risk, and the risk/benefit ratio for patients, particularly those at highest risk.