In patients with ST-elevation myocardial infarction (STEMI), fast reperfusion is associated with reduced morbidity and mortality. Many patients, however, do not meet the recommended standard times. Among the strategies considered to accomplish this task, prehospital ECG (PH-ECG) is advocated by international guidelines. International and Italian regional registries demonstrate the efficacy of PH-ECG to reduce both ischemic and first medical contact-to-balloon times in STEMI patients treated with primary angioplasty. Despite the available evidence, PH-ECG is still underused in the real world, without showing any significant increase in recent years. According to the LombardIMA registry, only 12% of the total population had a PH-ECG; in these patients median ischemic time was 154 vs 208 min when PH-ECG was not available. Median first medical contact-to-balloon time was 50 and 85 min, respectively. The use of PH-ECG showed also a trend for lower 30-day mortality, though not statistically significant. PH-ECG can also lead to early antithrombotic therapy (aspirin, clopidogrel or IIb/IIIa inhibitors), which is associated with better angiographic outcome. Data from the LombardIMA registry show that PH-ECG may play a relevant role in the management of STEMI networks, with less patients admitted to hospital without on-site cath-lab and reduced reperfusion delays in patients transferred from spoke to hub hospitals.