The efficacy of thrombolytic therapy in the elderly remains a topic of ongoing debate. Although elderly patients account for a disproportionate amount of cardiovascular mortality, they have typically been underrepresented in randomized clinical trials. A meta-analysis of these trials suggests a survival benefit, albeit small, of thrombolytic therapy in the elderly. Thrombolytic therapy, in combination with either glycoprotein IIb/IIIa inhibitors or low-molecular weight heparin, poses an increased hazard in the elderly. Observational studies of thrombolytic therapy in the elderly portray a far worse outcome than the randomized clinical trials and raise the possibility of increased mortality. To date, no randomized trial has compared thrombolytic and primary coronary intervention in the elderly. However, multiple observational studies indicate a low risk of intracerebral hemorrhage and improved survival when a strategy of primary coronary intervention is employed. Future trials and observational studies should elucidate the ideal reperfusion strategy in the elderly.