Acute ST-elevation myocardial infarction (STEMI) represents a cardiac emergency with a high early mortality. Over the last decades, prognosis of patients with STEMI has dramatically improved. This has primarily been a result of advances in coronary interventional techniques as well as medical therapy. Direct percutaneous recanalization of the infarct-related artery represents the gold standard in treating STEMI, specifically when performed within two hours after first medical contact. These timelines imply logistical challenges for ambulance and hospital services. Furthermore, the broad variety of antithrombotic (acetylsalicylic acid, P2Y12 and GPIIb/IIIa receptor antagonists) and antithrombin medication (heparins, direct thrombin inhibitors) requires a sound understanding of the current evidence, guidelines and the individual patient characteristics to offer optimal medical therapy to the individual patient.