Almost a half of all myocardial infarctions occur in those over 70 years of age and this is projected to rise further as the number of older patients in the total population increases. Following myocardial infarction, complications are more common in the older patient and the mortality outlook is much worse in those aged over 75 years. Guidelines generally favour the administration of thrombolysis post-myocardial infarction to older patients, although there is a lack of randomised clinical trials with thrombolysis in this group. Observational data, however, suggest that there is a significantly increased risk of mortality in patients aged over 75 years and this means the elderly are less likely to receive thrombolytic therapy, even when no contraindications are present. Randomised trials have shown that percutaneous coronary intervention is associated with a better outcome in the older patient. With the advances in antiplatelet therapy and the advent of intracoronary stents, this outcome is expected to improve further. The article also discusses therapeutic options in secondary prevention.