**1. Introduction**

Cardiovascular diseases are a primary cause of death in Europe, responsible for more than half of all deaths across the region, with heart disease or stroke the leading cause of death in all 52 countries [1]. Ischemic heart disease now accounts for almost 1.8 million deaths a year, or 20% of all deaths in Europe, albeit with large variations between countries [2]. There has been an overall declining trend in the mortality due to ischemic heart disease over the past three decades, however [3].

Outcomes in patients with ST-Elevation Myocardial Infarction (STEMI) are influenced by many factors, some of which could relate to how health care services are organized, such as the availability of emergency medical services based on STEMI networks, which can have an impact on the delay before a patient is treated. In patients clinically suspected of having myocardial ischemia and ST-segment elevation, reperfusion therapy needs to be initiated as soon as possible [4,5]. In the literature, some studies have shown that obtaining an electrocardiogram (ECG) before reaching the hospital significantly reduces the door-to-balloon time, and that subsequently admitting ambulances directly to the cardiac catheterization laboratory (CCL), bypassing the emergency room (ER), substantially reduces the time to primary percutaneous coronary intervention (PCI) [6,7], resulting in a significant time saving for patients [4,5]. Changes in health care service organization such as prehospital activation have led to the patients involved having the highest ejection fractions, and the shortest hospital stays [8], and other studies have reported a reduction in mortality too [9].

According to the literature, myocardial infarction managemen<sup>t</sup> may differ in relation to patients' characteristics, such as age, race and gender [10–12], and whether disparities in access to cardiac procedures translates into a different mortality risk is not known [13]. In recent years, there have been national and global efforts to rectify such health inequities, but few studies have investigated how successful they have been. One framework for action defined six strategies imperative for eliminating disparities in cardiovascular health care [14], and one of these strategies involves collecting health care data by ethnicity and gender to orient program development, implementation and assessment [15].

A study conducted at one American clinic showed that a systems-based approach to STEMI care reduced gender disparities and improved STEMI care and outcomes in women [16]. In another larger American study it emerged that a state-wide STEMI regionalization program was associated with improvements in treatment times for female, black, and elderly patients comparable with those for middle-aged, white, male patients [17]. Finally, in a recent European population-based study, socioeconomic inequity of access to revascularization was no longer apparent following the redesign of revascularization services in the South Wales Cardiac Network [18]. Such studies have been rather scarce in the European context, however. Hence the present study to assess the impact of the network implemented for AMI in the Veneto Region over the past 10 years (based on a 'hub and spoke' organizational model) in terms of the quality and outcome of the care process, and its efficacy in reducing health inequities.
