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Background: Timely reperfusion therapies (primary angioplasty and pre-hospital thrombolysis) remain a key component in improving the survival of patients with ST-segment elevation myocardial infarction (STEMI). The Lazio Region emergency organization has a complex mixed logistic (the large city of Rome, presence of complex orography), therefore the use of telemedicine technologies by the emergency medical system (EMS) is mandatory. Emergency clinical pathways (ECP) for the management of STEMI patients were designed, focusing on early pre-hospital diagnosis and best appropriate treatment through the ECG transmission and teleconsultation among EMS and cardiologists in coronary care units (CCU)., Methods: To evaluate the effectiveness of ECP-STEMI in the current practice, a prospective observational cohort study of ambulance-transported patients with cardiovascular symptoms was conducted in a selected area of the Lazio Region during a 6-month period. The implementation of the ECP was carried out by educational activities for the EMS personnel based on the "experiential learning" methods., Results: From October 2005 to March 2006, 287 patients were enrolled in the study and a pre-hospital ECG was performed in 66% of them. One hundred and fifty-two patients were referred to hospital and only 34 had discharged diagnosis of acute myocardial infarction, of whom 23 were STEMI. In the 34 acute myocardial infarction patients the medium time from "call to the EMS" to "arrival to the hospital" was 41 min (range 29-63 min) and 3 had their ECG telematically transmitted from the ambulance to the CCU. All of these cases were STEMI. Twenty-eight acute myocardial infarctions were discharged alive, 2 were transferred in other hospitals, 4 died. No patients received pre-hospital thrombolysis. Prior to the ECP implementation the ECG for STEMI patients has never been transmitted by EMS to the CCU in the Lazio Region., Conclusions: Our study suggests that adherence to ECP improved the appropriateness of STEMI patient referral and treatment in the CCU in the Lazio Region. The EMS personnel, during the study, showed a high interest in the protocol trying to change their current practice. The Regional Administration plans to expand the utilization of ECP to all regional emergency network (EMS and Emergency Departments) and to improve its use.