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Over the past 20 years, the widespread use of pharmacological and mechanical reperfusion therapies, as well as a faster delivery of care, has considerably improved survival in acute coronary syndromes. Primary percutaneous coronary intervention (PCI), in particular, has improved the long-term prognosis of patients with ST-segment elevation myocardial infarction. There are, however, particular subgroups of individuals (elderly patients, women and patients with chronic kidney disease) that require special management during PCI because of their higher risk profile and the presence of numerous other concomitant pathologies. To date, a general consensus on the management of these patients in different phases of their clinical course is still lacking, but it is largely acknowledged that patients with the highest risk profile are often denied a reperfusion treatment.