Pre-Hospital Delay in STEMI: A Narrative Review of Symptom Onset-to-First Medical Contact Across High-Income and Low-
Javeria Akhter1, Zain Ul Abedin2, Huzafa Ali3
1Indus Hospital and Health Network, Karachi, Pakistan.
Insights
Pre-hospital delay in ST-segment elevation myocardial infarction (STEMI) significantly impacts patient outcomes, especially in low- and middle-income countries. Addressing this requires strengthening emergency medical services (EMS) and improving healthcare systems, not just individual awareness.
Area of Science:
- Cardiology
- Public Health
- Health Systems Research
Background:
- ST-segment elevation myocardial infarction (STEMI) is a leading cause of cardiovascular death globally.
- Outcomes for STEMI patients vary significantly between high-income countries and low- and middle-income countries (LMICs).
- Pre-hospital delay is a critical factor contributing to total ischemic time, limiting the effectiveness of timely reperfusion therapies.
Purpose of the Study:
- To review and synthesize evidence on pre-hospital delay in STEMI.
- To analyze pre-hospital delay through a health-system performance and equity lens.
- To identify key factors contributing to pre-hospital delay in STEMI care.
Main Methods:
- A narrative review of studies published between 2000 and 2025.
- Searches conducted in PubMed, Embase, and Scopus databases.
- Evidence interpreted using a conceptual framework of four delay pathways: recognition, decision-making, access, and system readiness.
Main Results:
- In high-income countries, median symptom onset-to-first medical contact (FMC) intervals are 60-120 minutes, with organized STEMI networks and higher EMS use, though inequities persist.
- In LMICs, symptom onset-to-FMC delays often exceed 300 minutes, sometimes reaching over 480 minutes.
- Limited EMS coverage and fragmented referral pathways are major drivers of delay in LMICs.
Conclusions:
- Pre-hospital delay in STEMI is complex and inequitable, necessitating integrated health system interventions.
- Recommendations include strengthening EMS, improving referral networks, enhancing early diagnostic capabilities, and implementing financing and governance mechanisms.
- Integrating emergency cardiac care into universal health coverage and non-communicable disease strategies can reduce STEMI mortality and global inequities.
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.
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