Primary percutaneous coronary intervention (PPCI) is the optimal reperfusion strategy for ST-elevation myocardial infarction (STEMI) patients when performed in a timely manner by experienced providers. Unfortunately, only 25% of US hospitals have percutaneous coronary intervention (PCI) capability. Transfer for PPCI has also been shown to improve outcomes if transfer times are short and PCI can be performed within 90 minutes. However, many STEMI patients cannot be transferred in a timely fashion because of long distances, adverse weather, or process-of-care delays. Recent data support strategies that combine fibrinolysis with transfer for PCI under these circumstances. The critical issue that is still debated is the timing of PCI (immediate vs delayed vs rescue). The significance of time to reperfusion to mortality is important but less critical for PCI than for fibrinolysis, but time still matters. To optimize time to reperfusion for STEMI patients, all hospitals need to have predetermined protocols in place based on hospital characteristics and proximity to a catheterization laboratory.