Despite major advances in reperfusion therapy and pharmacological management, acute myocardial infarction (AMI) remains one of the leading causes of mortality and morbidity worldwide. Conventional treatment strategies primarily focus on restoring coronary blood flow to ischemic myocardium; however, their ability to regenerate damaged cardiac tissue remains limited. In recent years, exosomes have emerged as a promising cell-free therapeutic approach for cardiac repair following AMI. Exosomes are nanosized extracellular vesicles secreted by various cell types that carry diverse bioactive molecules, including microRNAs, proteins, lipids, and signaling factors, which mediate intercellular communication and regulate multiple biological processes involved in myocardial healing. Emerging experimental and preclinical evidence suggests that exosome-based therapy may attenuate inflammation, reduce cardiomyocyte apoptosis, enhance angiogenesis, modulate immune responses, and promote myocardial regeneration following ischemic injury. Compared with conventional stem cell therapy, exosomes offer several advantages, including lower immunogenicity, reduced risk of tumorigenicity, improved stability, and easier storage and handling. Furthermore, engineered exosomes and targeted delivery systems are being investigated to enhance therapeutic specificity and efficacy in cardiovascular diseases. In addition to their therapeutic potential, circulating exosomes are also being explored as diagnostic and prognostic biomarkers for the early detection and monitoring of AMI. This review highlights the biological characteristics of exosomes, their mechanisms of action in myocardial repair, current experimental and clinical evidence, and future perspectives of exosome-based therapeutics in the management of AMI.