Although the observations from the Swedish STEMI registry showing an association between the increased use of evidence-based treatments and declining mortality rates after STEMI are encouraging,18 additional efforts to improve patient outcomes are needed. There is widespread acknowl- edgment that progress in closing existing knowledge and per- formance gaps will require contributions from a wide range of investigators, dedicated clinicians, hospital and health plan administrators, regional emergency response systems, and both government and private payers.631 12.1. Patient Awareness Delay times from onset of symptoms to activation of STEMI care pathways remain unacceptably long.51,631 Multicultural efforts to educate, reassure, and motivate at-risk patients and their families are needed. Comparable efforts to improve adher- ence and attention to healthy lifestyle behaviors as the corner- stones of secondary prevention are required at time of discharge and as an integral feature of cardiac rehabilitation programs. 12.2. Regional Systems of Care The adoption of regional systems of care for patients with STEMI across diverse geographical areas has proved challeng- ing, and inappropriate delays to initiation of reperfusion ther- apy are common.632 As previously emphasized, attention should be focused on reducing the total ischemic time, from onset of symptoms to successful reperfusion. Several factors in addi- tion to patient activation of EMS contribute to delays, not all of which can be reconciled. 