It is well established that rapid and complete reperfusion in ST-elevation myocardial infarction reduces infarct size and improves long-term morbidity and mortality rates. Randomized clinical trials demonstrate that primary angioplasty (percutaneous coronary intervention [PCI]) is superior to fibrinolytic therapy in reducing mortality, reinfarction, and recurrent ischemia if performed in a timely manner by an experienced team. Despite this evidence, a minority of patients are treated with primary PCI in the United States. Efforts to improve access and to develop systems that facilitate the availability of timely primary PCI are being addressed. Suggested solutions include coordination of emergency medical services (EMS) systems, performance of 12-lead electrocardiography in the ambulance, and early notification of the catheterization laboratory team. Improved access would require limited expansion of hospitals capable of primary PCI, particularly in rural areas. Although these strategies may help, there is growing enthusiasm for the development of primary PCI centers, with triage of patients to these centers through either an EMS bypass system or an interhospital transfer system.