Persons 75 years of age or older constitute 6.1% of the US population but account for 36% of acute myocardial infarctions (MI) and 60% of deaths. Unfortunately, despite the fact that patients over age 75 represent a large subgroup with an exceptionally high case-fatality rate, most randomized clinical trials have enrolled few patients in this group. As a result, therapeutic recommendations for managing acute MI in the very elderly are often extrapolated from studies conducted in younger patients. This article reviews current evidence-based guidelines for early treatment of acute MI in the elderly. As in younger patients, aspirin, beta blockers, and angiotensin-converting enzyme inhibitors should be considered standard therapy in appropriately selected elderly patients. Although the benefits of reperfusion therapy (i.e., thrombolysis and primary angioplasty) are less well established, advanced age per se should not be considered a contraindication to the use of these interventions. Given the relative paucity of data in the very elderly, additional studies are needed to define optimal pharmacologic and nonpharmacologic treatment of acute MI in this rapidly growing, high-risk population.