The commonest cause of acute myocardial infarction involves the rupture or erosion of vulnerable atherosclerotic plaques followed by aggregation of platelets and subsequent thrombus formation, leading to partial or complete epicardial coronary arterial occlusion. Over the last 25 years, advancement in therapeutic options for acute myocardial infarction has resulted in substantial improvement in morbidity and mortality. As a result, the absolute risk reduction of in-hospital deaths for patients presenting with STEMI has been on the decline in the last decade. The focus of the treatment for acute myocardial infarction involves achieving epicardial and microvascular patency, prevention of recurrent ischaemic events while balancing the risk of bleeding. This involves antiplatelet and antithrombotic therapies or fibrinolytic agents when timely performance of primary percutaneous coronary intervention is not possible. We review the evolution of treatment strategies for STEMI that has contributed to the improvement in patient outcome.