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Background The use of myocardial reperfusion—mainly via angioplasty—has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development. Methods Setting: Greater Paris Area (Ile-de-France). Data Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h). Parameters Demographic, decision to perform reperfusion and outcome (in-hospital mortality). Primary endpoint Reperfusion decision rate by decade over age 70. Secondary endpoint Outcome. Results We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52–73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years. The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26–0.68) in patients over 90 years. Conclusion the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age. [ABSTRACT FROM AUTHOR]