Pre‐Hospital Delay in STEMI: A Narrative Review of Symptom Onset–to–First Medical Contact Across High‐Income and Low‐ and Middle‐Income Countries

AIM: ST-segment elevation myocardial infarction (STEMI) remains a major contributor to global cardiovascular morbidity and mortality, with outcomes varying considerably between high-income and low- and middle-income countries (LMICs). Although advances in reperfusion therapy and improvements in hospital-based performance have decreased in-hospital delays, pre-hospital delay remains one of the largest components of total ischemic time, thereby restricting the survival benefit of timely reperfusion. METHODS: This narrative review synthesizes evidence on pre-hospital delay in STEMI and interprets delay through a health-system performance and equity lens rather than viewing it only as an individual behavioral issue. Relevant studies were identified through a search of PubMed, Embase, and Scopus (2000-2025). Evidence was interpreted using a conceptual framework comprising four pathways through which pre-hospital delay is produced: recognition, decision-making, access, and system readiness. RESULTS: Across multiple observational studies and registry reports, median symptom onset-to-first medical contact intervals in high-income countries are typically 60-120 min, supported by organized STEMI networks and higher EMS utilization, although inequities persist among vulnerable population. In several LMIC settings, symptom onset-to-FMC delays frequently exceed 300 min and may extend beyond 480 min, driven by limited EMS coverage and fragmented referral pathways. CONCLUSION: Overall, pre-hospital delay in STEMI is a multidimensional and inequitable phenomenon suggesting the need for integrated approaches beyond awareness campaigns, including EMS strengthening, coordinated referral networks, early diagnostic capacity, financing protections, and governance and accountability mechanisms. Positioning emergency cardiac care within universal health coverage and national non-communicable disease strategies may reduce avoidable STEMI mortality and narrow global inequities.