OBJECTIVE The management strategies after acute myocardial infarction (AMI) have been evolving from simple supportive treatment to various protocols of thrombolytic therapies, and then to mechanical revascularization by balloon angioplasty in recent years. However, controversies still exist between which is the best treatment approach. METHODS An extensive analysis was carried out in over 120 articles reported recently in the literature. RESULTS Most reported series have shown that direct angioplasty is a feasible and safe option for the management of acute myocardial infarction. Large scale randomised studies comparing direct angioplasty versus thrombolytic therapy in acute myocardial infarction have also reported very favourable acute and long term outcomes by direct angioplasty as compared to thrombolytic therapy. The results are at least equivalent, if not better, by direct angioplasty. Acute results include better reperfusion rate of infarct related artery, less bleeding and stroke complications, shorter hospital stay, and most importantly, lower in-patient mortality (around 2% in direct PTCA group versus 6% in thrombolysis group) and less recurrent ischaemic event (around 10% in direct PTCA group versus 30% in thrombolysis group). Despite some delay in the commencement of treatment by direct angioplasty than thrombolytic therapy, the left ventricular function remains comparable in the two groups and the overall long term outcomes are very favourable with direct angioplasty. Specific indications for direct angioplasty include patients with cardiogenic shock after AMI and patients with contraindications to thrombolysis. No reflow phenomenon is still an issue of concern. It is in general contraindicated to use angioplasty after failure of thrombolysis. The cost implication is not far exceeding that of thrombolysis therapy. CONCLUSIONS Direct angioplasty for acute myocardial infarction should be established as a treatment option if the circumstances allow. Planning should be carried out at the hospital and community level in order to make direct angioplasty a high priority treatment option for patients with acute myocardial infarction.