We conducted a postal survey amongst members of the British Cardiac Society to determine current strategies for the detection and management of failed thrombolysis for acute myocardial infarction. The response rate was 290/387 (75%). On-site cardiac catheterisation facilities are available to 162 (60%), 112 (41%) of which are prepared for urgent angiography +/- angioplasty. Streptokinase is the preferred routine thrombolytic agent (n = 242, 90%). After thrombolysis, 121 (45%) respondents rarely search for evidence of reperfusion; a further 55 (20%) confine their search to selected cases. Practice varies amongst those with an active management strategy following proven failed thrombolysis (n = 149, 55%): 50 (19%) perform urgent angiography +/- angioplasty, 49 (18%) administer another thrombolytic agent, 6 (2%) administer another dose of the same agent and 44 (16%) combine these approaches. Transfer to an interventional centre is considered by only 11/106 (10%) without on-site access to cardiac catheterisation. These data indicate considerable variation in the management of failed thrombolysis. Randomised, controlled trials are required to elucidate optimal treatment for this common and important clinical situation.