Successful revascularisation of patients presenting with STEMI requires rapid transfer to a PCI capable unit and concomitant treatment with antiplatelet and antithrombotic drugs. A delicate balance exists between thrombosis and bleeding and a perfect combination of agents is yet to be found. An intimate relationship between the intravenous antithrombotic and oral antiplatelet agents exists and these must be considered in the selection/tailoring of treatment. Oral antiplatelet therapies provide long-term platelet inhibition but are hampered by delayed onset of action in acutely unwell patients. Future strategies may include upstream administration of drugs by the first medical contact or acute treatment with an intravenous platelet inhibitor.