Despite the fact that patients with acute myocardial infarction over age 75 represent a large subgroup with high mortality, most randomised clinical trials have included relatively few patients in this group. As a result, therapeutic recommendations for managing acute MI in the very elderly are often extrapolated from studies conducted in younger patients. This article reviews current guidelines of early treatment of acute myocardial infarction in the elderly. As in younger patients aspirin, beta blockers and angiotensinconverting enzyme inhibitors should be considered a standard therapy in appropriately selected patients. Although the benefits of reperfusion therapy (thrombolysis and primary angioplasty) are less well established, advanced age per se should not be considered a contraindication to the use of these interventions. Therapy should be individualised according to the patient’s clinical condition.