For patients who call 9-1-1, direct care begins with FMC, defined as the time at which the EMS provider arrives at the patient s side. EMS person- nel should be accountable for obtaining a prehospital ECG, making the diagnosis, activating the system, and deciding whether to transport the patient to a PCI-capable or non PCI- capable hospital. Consideration should be given to the devel- opment of local protocols that allow preregistration and direct transport to the catheterization laboratory of a PCI-capable hospital (bypassing the ED) for patients who do not require emergent stabilization upon arrival. Although false posi- tives are a concern when EMS personnel and/or emergency physicians are allowed to activate the cardiac catheteriza- tion laboratory, the rate of false activations is relatively low (approximately 15%) and is more than balanced by earlier treatment times for the majority of patients for whom noti- fication is appropriate.108 114 The concept of what constitutes false activation is evolving.115,116 For patients who arrive at or are transported by EMS to a non PCI-capable hospital, a decision about whether to transfer immediately to a PCI- capable hospital or to administer fibrinolytic therapy must be made. Each of these scenarios involves coordination of dif- ferent elements of the system. On the basis of model systems of STEMI care in the United States and Europe,77,78,117 121 Mission: Lifeline recommends a multifaceted community- wide approach that involves patient education, improve- ments in EMS and ED care, establishment of networks of STEMI-referral (non PCI-capable) and STEMI-receiving (PCI-capable) hospitals, and coordinated advocacy efforts to work with payers and policy makers to implement healthcare system redesign. Detailed information about this program can be found on the AHA website.122 Several factors should be considered in selecting the type of reperfusion therapy (Figure 2). 