Background: the potential benefits of routine early intervention after thrombolysis include prevention of re-infarction, recurrent ischemia, and reduction of the infarct size and mortality. Aim of the work: the purpose of this study is to compare routine early coronary angioplasty in patients with acute anterior STEMI after successful thrombolysis versus ischaemia-guided coronary angioplastyas regards the occurrence of MACCE. Study design: a total number of 100 patients with acute anterior STEMI received thrombolytic therapy and then were randomly assigned to either routine invasive strategy or ischemia based strategy based on risk stratification by stress myocardial perfusion scan done within 30 days of the onset of AMI with subsequent CA after demonstration of residual myocardial ischemia and or good viability. Results: the cumulative incidence of MACCE including recurrent ischemia, stroke, MI, HF or mortality was significantly lower in theroutine early invasive strategy. Conclusion: STEMI patients who cannot undergo timely primary PCI should receive prompt fibrinolysis followed by early routine invasive strategy.