Abstract Body (Do not enter title and authors here): Introduction: Fibrinolysis is the treatment of choice for patients with ST-elevation acute myocardial infarction (STEMI) who cannot reach door-to-balloon time for primary reperfusion therapy (PCI) 1. This therapy is widely used in some countries in Europe and Brazil2. However, these patients who undergo thrombolysis have a higher mortality rate compared to patients who undergo primary PCI3. The objective of the study is to evaluate the outcomes of mortality, reinfarction and stroke in patients with STEMI who underwent thrombolysis outside referral centers (community hospitals and inside ambulances) versus patients who underwent primary PCI. Methods: We performed a systematically review and meta-analysis of randomized control trials (RTCs) comparing of pre-hospital thrombolysis (PHT) with primary coronary intervention (PCI). PubMed, Embase and Cochrane databases were searched from April 2024 with the following search terms: ‘STEMI’, ‘myocardial infarction’[Mesh],’pre hospital’,’thrombolysis’,PHT, ‘thrombolytic therapy’. We used random-effects model to estimate the Risk Ration (RR) with 95% CI. Heterogeneity was examined with I2 statistics. We also performed leave-one-out sensitivity analyses and used Review Manager 5.4 for statistical analysis. The study was registered on PROSPERO: CRD42024547309. Results: A total of 1890 patients from 3 studies RTCs were included. Pre-hospital thrombolysis was used to treat STEMI in 940 patients (49%). Follow-up time varied from 4.6 to 5 years. The average age was 60.3 years. The anterior infarction on the ECG was similar between groups: average 43% (PHT) and 41.6% (PCI). Pre-hospital thrombolysis was associated with a higher risk of reinfarction ( RR 2.33; 95% CI 1.30-4.16; p=0.004; I2=0%) and composite outcomes of stroke, mortality and reinfarction(RR 1.67; 95% CI 1.25-2.23; p=0.0005; I2=0%). No significant differences were found between treatment groups regarding mortality (RR 1.23; 95% CI 0.70-2.18; p=0.47; I2=42%) and stroke (RR 3.82; 95% CI 0.54-27.23; p=0.18; I2=38%). Conclusion: This study suggests that pre-hospital thrombolysis is associated with a higher risk of reinfarction. More randomized studies on patients treated in a pre-hospital environment are needed to better investigate this question.