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Aims - The objective of our study is to compare pharmaco-invasive strategy (PhIS) in terms of safety and efficacy, with primary percutaneous coronary intervention (pPCI) strategy as standard therapy for STEMI patients from remote areas. Background - At present, primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy for STEMI patients. However, despite pPCI being the gold standard, it is not always achievable due to variables such as lack of cardiac catheterization services and delays in the first medical contact-to-balloon time. Methods - This observational study is based on a prospective analysis of a cohort of 157 patients with ST-elevation myocardial infarction, over nine months, at Elias University Hospital (EUH). The study assessed the safety and efficacy of a sequence of fibrinolytic therapy in the first contact hospital before being referred to our center for PCI (PhIS, 35 patients, 22.29%) versus angioplasty alone (pPCI, 122 patients, 77.70%) during hospitalization. The primary outcomes studied were in-hospital death, and major adverse cardiac events (MACE), while secondary outcomes were the length of in-hospital stay, and the safety of the procedure. Results - The median reperfusion time was lower for the PhIS group compared to the primary PCI group (4 hours, IQR:6.25 vs 7 hours, IQR:12.38, p<0.05). The left ventricular systolic function (%) on arrival at EUH was higher in the PhIS group compared with the PCI alone group (46.55; 95%CI 42.42-49.15 vs 41.73; 95%CI 39.91-43.34; p=0.04). The mean number of diseased vessels, including the culprit-lesion, were similar in the two groups (2.84 vs 2.82, p=0.09). The in-hospital mortality rate was lower in the PhIS group than in the primary PCI group (1 patient; 2.9% vs 18 patients; 14.80%; p=0.05), while the number of in-hospital major adverse cardiac events (MACE) was not significantly different (17.10% vs 26.20%; p=0.27). There was no difference of the median length of hospitalization (6 days, IQR:2 vs 5 days, IQR:3; p=0.67) for the PhIS, and primary PCI groups, respectively. The safety endpoints of the procedures were similar in the two groups. Conclusions - Pharmaco-invasive strategy (PhIS) had clinical and procedural outcomes (in-hospital MACE, length of in-hospital stay) similar to primary percutaneous coronary intervention (pPCI), in case of long distances to catheterization laboratories. Efficient thrombolysis makes PhIS a viable alternative in saving lives with a lower rate of in-hospital death than pPCI. Performed thrombolysis in a local non-PCI center and referral of the STEMI patients to a 24/7 catheterization laboratory may be a good option for areas where the infrastructure of such facilities is weak. [ABSTRACT FROM AUTHOR]