Prehospital Fibrinolytic Therapy The time delay from symptom onset to treatment can be short- ened by administration of prehospital fibrinolytic therapy by a trained EMS unit either with a physician on board142 147 or with a hospital-based physician148 152 in direct contact, especially in rural areas. Multiple randomized controlled trials (RCTs) have demonstrated the safety and feasibility of prehospital fibrino- lytic therapy, with decreased treatment times ranging from 30 A meta-analysis of 6 higher- quality RCTs revealed an approximately 60-minute reduction in time from symptom onset to delivery of fibrinolytic therapy with prehospital versus hospital-based administration, with a corresponding 17% reduction in risk of all-cause hospital Analysis of a subgroup of patients enrolled in the CAPTIM (Comparaison de l Angioplastie Primaire et de la Thrombolyse) trial within 2 hours of symptom onset showed a significantly lower 5-year mortality rate for patients treated with prehospital fibrinolysis than for patients managed with primary PCI (P=0.04).123,142 These salutary results for early presenters were confirmed in a subsequent analysis of com- bined data from the CAPTIM and WEST (Which Early ST- Elevation Myocardial Infarction Therapy) trials.155 Data from the USIC (Unit de Soins Intensifs Coronaires) Registry and the Swedish Registry of Cardiac Intensive Care also suggest that prehospital fibrinolytic therapy may lower STEMI mor- At the present time, however, prehospital fibrinolytic ther- apy is not used in most communities in the United States. EMS in rural areas, where prehospital fibrinolysis would poten- tially be of benefit, often have neither the resources to train paramedics nor the funding for necessary equipment. Use of prehospital fibrinolysis is more widespread in some regions of Europe and the United Kingdom. The writing committee endorses the need for further research into the implementation of prehospital strategies to reduce total ischemic time. 3.6. 