• The emergency medical system is France is very well established and often includes physicians. This has undoubtedly contributed not only to the high prehospital fibrinolysis rate (66% of patients), but also to the early initiation

of treatment. As a result, PCI-related delay kinase inhibitors (defined as FMC-to-fibrinolysis time subtracted from FMC-to-PPCI time) was considerable (105 minutes compared to 78 minutes in STREAM) and might have contributed to the favorable outcomes observed in the fibrinolysis group. This setup and high rate of prehospital fibrinolysis is clearly difficult to reproduce in many countries/regions. What have we learned? Timely PPCI remains the reperfusion strategy of choice in patients with acute STEMI. Findings from STREAM and FAST-MI lend further support to the adoption of a pharmacoinvasive

strategy in areas where this cannot be achieved. In this setting, concerted efforts to improve emergency medical services is essential. Prehospital fibrinolysis should probably be considered in remote areas where transport time to a hospital is unacceptably long. Besides proper training of EMS personnel, this can be facilitated by wireless transmission of 12-lead ECGs to an offsite cardiologist, a practice which is currently adopted in many areas around the world. 16 Standardized inter-hospital transfer protocols should be established to allow for routine post-fibrinolysis coronary angiography (and PCI when appropriate) within the recommended time frame, as well as urgent rescue PCI for patients with failed thrombolysis.

It is still unclear whether late presenters (>3 hours) and elderly patients derive a similar benefit from such approach. Finally, while system-related delays have been the focus of numerous studies and scrutiny, which have resulted in remarkable improvements in emergency medical services response, transfer times, door-to-needle and/or door-to-device times; 17 one should not forget that the ultimate objective in patients with acute STEMI is reducing the total ischemic time which also includes the time Brefeldin_A delay to FMC. The latter has received significantly less attention, which in part is related to difficulties in accurate measurement, given its susceptibility to recall bias and the fact that symptoms may be vague or intermittent in a considerable number of STEMI patients. It is worth noting that this patient-related delay – on average – constituted approximately 60% and 30% of the total ischemic time in STREAM’s pharmacoinvasive and PPCI populations respectively, while one third of FAST-MI’s population had a time-to-FMC of more than 120 minutes (which on its own exceeds the maximum allowed system-related delay). This delay is almost certainly longer in less developed regions/countries where emergency services and public awareness/education programs are not well-established.