Conclusion
This study underscores the importance of total ischaemic time and highlights the importance of system delays in influencing outcomes after STEMI. An association between P-RD and clinical outcome has been demonstrated for the first time in a prospective study comparing directly PI with P-PCI. The results indicate that when ambulance systems and community hospitals face a P-RD of >60 min, a PI strategy as used in STREAM should be least considered. The PI strategy may be applicable as the best reperfusion option in the many parts of the world when P-PCI cannot be delivered expeditiously.