Recent advances have caused a major shift in the way ST-elevation myocardial infarctions are managed. This review explores the pharmacological and interventional techniques that have evidence for improving outcomes and the landmark trials that have sparked change. The new P2Y₁₂ inhibitors, ticagrelor and prasugrel, have been shown to be superior to clopidogrel in STEMI patients undergoing primary percutaneous coronary intervention. Concurrently, many technical aspects of percutaneous coronary intervention have been further clarified by trial data, with bare-metal stents, routine thrombus aspiration and femoral access showing evidence of inferiority. Ongoing trials will provide more information on the role of non-culprit lesion PCI, bioresorbable vascular scaffolds, mechanical devices in persistent ischaemia and early automatic implantable cardioverter-defibrillators for inducible ventricular tachycardia.