After failed thrombolysis, rescue coronary angioplasty is performed with the aim of restoring complete flow in the infarct-related artery. The clinical benefit of this strategy has been debated in few clinical trials during the early '90s, and high procedure-related risks, low success and early reocclusion rates seemed to outweigh the benefit of mechanical recanalization. The RESCUE trial and, more recently, data from the GUSTO angiographic substudy supported the hypothesis of a better outcome among patients aggressively managed after failed thrombolysis. Noninvasive identification of such patients must be accomplished monitoring electrocardiogram and biochemical markers of myocardial necrosis. Further improvements in the management of candidates to rescue coronary angioplasty can be obtained with a more liberal use of intra-aortic balloon pump among subjects admitted in cardiogenic shock; stents and platelet aggregation inhibitors could reduce early reocclusion, but randomized data are needed to test this hypothesis.