This study highlights the significant impact of Chest Pain Centers on improving the diagnosis, treatment, and long-term outcomes of ST-segment elevation myocardial infarction patients in Ningxia, an underdeveloped region in China. CPC implementation reduced 30-day and 3-year mortality rates (6.68–4.53% and 11.86–8.55%, respectively) and MACEEs rates (10.00–7.90% and 23.12–18.86%). These findings underscore the critical role of CPC in addressing disparities in cardiovascular care and enhancing regional healthcare capabilities, especially in resource-limited settings.

In our study, we found CPC establishment as an independent protective factor against both mortality and MACCEs. Adjusted hazard ratios for all-cause mortality were 0.59 at 30 days, 0.55 at 1 year, and 0.55 at 3 years, while HR for MACCEs were 0.72, 0.80, and 0.71 over the same timeframes. Kaplan–Meier survival curves further confirmed the survival benefits, showing significantly higher survival probabilities in the post-CPC group. These findings align with international evidence. In the United States, Ross et al. demonstrated that CPC-accredited hospitals achieve better acute myocardial infarction management outcomes compared to non-accredited hospitals [23]. Similarly, Keller et al. in Europe reported superior 1-year outcomes for acute coronary syndrome (ACS) patients treated in chest pain units compared to traditional emergency departments [24]. In Asia, Alexander et al. showed that a CPC-like model in South India improved PCI utilization and reduced 1 year mortality [25]. Previous studies in China have shown that CPC accreditation is associated with improved in-hospital management and outcomes for ACS and AMI patients [26,27,28]. However, evidence on the long-term benefits of CPC in economically underdeveloped regions remains limited. The study fills a critical gap by providing robust data on long-term outcomes in Ningxia, demonstrating sustained benefits over a 3 year.

CPC implementation achieved substantial progress in reducing door-to-balloon (D2B) times, from 117.7 min pre-CPC to 46.9 min post-CPC, and increasing the proportion of patients receiving primary PCI within 90 min of hospital admission from 24.47–60.41%. Studies have consistently demonstrated that every 10 min reduction in D2B time significantly lowers the risk of in-hospital mortality [29, 30]. Although these improvements are notable, the overall 24 h reperfusion therapy rate remains lower than in developed countries such as the United States (95% in 2016) and Germany (78% in 2011) [31, 32]. Similarly, the proportion of patients receiving thrombolysis within 30 min of arrival increased from 0.88% pre-CPC to 4.1% post-CPC but still lags behind levels seen in the United States (92–94% in 2010) [33]. Early thrombolytic therapy is crucial for STEMI patients who cannot receive primary PCI promptly, as it can significantly reduce infarct size, improve left ventricular function, and decrease mortality. Evidence suggests that thrombolysis administered within the first 30 min of symptom onset offers the greatest survival benefits, with a 30% reduction in mortality compared to delayed treatment [34, 35]. These delays can be attributed to uneven medical resource distribution, insufficient diagnostic capabilities, and limited training among primary healthcare workers. Addressing these barriers requires targeted interventions, such as strengthening grassroots medical training and promoting telemedicine systems to reduce delays in diagnosis and treatment decisions.

CPC implementation not only refined acute treatment pathways but also fostered adherence to guideline-directed medical therapy (GDMT). Early access to percutaneous coronary intervention and evidence-based pharmacological therapies, such as dual antiplatelet therapy and high-intensity statins, are fundamental aspects of CPC protocols [8, 36]. GDMT has been shown to play a pivotal role in reducing major adverse cardiac and cerebrovascular event rates and improving survival outcomes in STEMI patients. For instance, the use of dual antiplatelet therapy is associated with a significant reduction in ischemic events and stent thrombosis, while high-intensity statins reduce recurrent cardiovascular events and improve overall mortality [37, 38]. This study observed improved use of beta-blockers within 24 h and P2Y12 receptor inhibitors at discharge, reflecting enhanced adherence to evidence-based practices. Beta-blockers are critical for reducing myocardial oxygen demand, limiting infarct size, and improving long-term outcomes, particularly when administered early [39]. Similarly, timely initiation of P2Y12 receptor inhibitors has been demonstrated to lower platelet reactivity and reduce thrombotic complications, contributing to better prognosis in STEMI patients [40]. These interventions collectively highlight the importance of incorporating GDMT into routine CPC protocols, which are essential for reducing MACCEs rates and improving long-term survival.

Despite the substantial contributions of Chest Pain Centers (CPCs), their implementation in underdeveloped regions faces several persistent challenges that must be addressed to maximize their effectiveness. One of the foremost obstacles is economic constraint. Establishing and maintaining CPCs demands considerable financial investment, including infrastructure upgrades, equipment procurement, and personnel training. In low-resource settings, many hospitals struggle with budget limitations, hindering the long-term sustainability of CPC operations [25]. To overcome this, policymakers should consider innovative funding strategies such as government subsidies, public–private partnerships, and performance-based incentive programs [41].

In addition to financial barriers, a shortage of skilled healthcare professionals poses a critical challenge. Effective STEMI care within CPCs depends on the coordinated work of emergency physicians, cardiologists, nurses, and emergency medical service (EMS) providers. However, economically disadvantaged regions often suffer from workforce shortages and high staff turnover. Addressing this issue requires the implementation of standardized CPC-specific training and ongoing continuing medical education (CME) programs to improve healthcare providers’ competencies in diagnosis, risk stratification, and timely reperfusion therapy.

Furthermore, limited public awareness and pre-hospital delays significantly hinder early STEMI management. Many patients in rural and underserved areas are unaware of heart attack symptoms, lack access to emergency transportation, or rely on local clinics and self-medication, which leads to delayed hospital arrival. Public health campaigns that educate communities about symptom recognition, emphasize the urgency of contacting emergency services, and promote the use of pre-hospital ECG screening are essential to reduce delays and improve triage efficiency.

By addressing these interconnected barriers, CPCs can be more effectively integrated into underdeveloped healthcare systems, ultimately enhancing equity and outcomes in acute cardiac care.

To ensure the sustainability and scalability of Chest Pain Centers (CPCs) in resource-limited regions, a coordinated set of policy-level strategies is essential. Government leadership should play a central role by prioritizing CPC development in underserved areas. This includes allocating targeted funding, incorporating CPCs into national STEMI care networks, and establishing region-specific accreditation standards to guide implementation and quality assurance.

Equally important is the strengthening of regional STEMI networks through a hub-and-spoke model. In this approach, tertiary hospitals function as central referral hubs, supporting smaller, rural healthcare facilities in optimizing patient transfer pathways and resource allocation. This structure fosters a more coordinated and efficient continuum of care, particularly in geographically dispersed or low-resource settings. The integration of telemedicine and artificial intelligence (AI)-based decision support also holds great promise. Expanding telemedicine capabilities within CPCs can enhance real-time remote electrocardiogram (ECG) interpretation, support earlier STEMI identification, and guide pre-hospital triage decisions. Moreover, AI-driven risk prediction tools may improve clinical decision-making by enabling more accurate and individualized treatment strategies [42].

By systematically addressing the financial, workforce, and infrastructure-related barriers, these approaches can significantly enhance the reach and impact of CPCs. Ensuring timely and equitable STEMI care in underdeveloped areas not only improves clinical outcomes but also strengthens the broader healthcare system. Future research should aim to evaluate the effectiveness of these strategies and identify scalable best practices to guide CPC implementation in resource-constrained environments.

This study offers valuable insights to both cardiovascular medicine and health systems research. First, this study stands out as one of the initial pieces of evidence showcasing the long-term benefits of CPC establishment on STEMI outcomes in a low- to middle-income country (LMIC). This expands the current comprehension of CPC effectiveness, which has primarily been studied in high-income settings. Second, the study uses a large, real-world dataset from the Ningxia Myocardial Infarction Registry, ensuring robust external validity and reflecting the realities of clinical practice in China. Third, this study highlights the crucial role of collaborative, multi-faceted healthcare models for vulnerable populations. By demonstrating sustained reductions in mortality and MACCE rates over a 3 year period, the study highlights the value of CPCs not only in acute care but also in long-term secondary prevention. These results contribute to the growing evidence base supporting health system reforms aimed at optimizing STEMI care in resource-limited settings. Finally, this study bridges a critical evidence gap by quantifying the long-term survival benefits and event-free outcomes associated with CPCs, providing crucial insights for policymakers and healthcare administrators.

This study has several limitations that warrant consideration. First, due to its retrospective cohort design, causal inferences cannot be firmly established, despite adjustments for multiple confounding factors via multivariable Cox regression. Despite acknowledging the potential impact of baseline differences on our study outcomes, we choose to employ multivariable Cox regression rather than Propensity Score Matching (PSM) to address this issue. While PSM remains a viable method, it has the potential to decrease statistical power due to unmatched cases and may introduce bias if matching is not fully achieved [43, 44]. Future studies may consider incorporating PSM or more advanced analytical techniques such as time-series or multilevel modeling to further validate our findings and better isolate the effect of CPC implementation. Second, the study was conducted at a single center, which may limit the generalizability of the results to other regions in China with varying healthcare infrastructures. Multicenter studies are needed to explore regional differences and confirm the broader applicability of CPC-related improvements. Third, while the study focused on long-term mortality and MACCEs, it did not include other important outcomes such as healthcare costs, resource utilization, or health-related quality of life. Although we observed reduced hospital stays and costs in the post-CPC group, a formal cost-effectiveness analysis was not performed. Moreover, patient-reported outcomes and quality-of-life metrics were not captured, despite their growing recognition as essential endpoints in cardiovascular research. Fourth, our registry did not systematically collect data on medication adherence, participation in secondary prevention programs, or bleeding complications. In particular, major hemorrhagic events-which are critical to assess in STEMI patients receiving antithrombotic therapy-were incompletely recorded. Future research should incorporate standardized bleeding assessments, such as those defined by the Bleeding Academic Research Consortium (BARC), and track adherence through real-world data sources (e.g., pharmacy records or follow-up surveys). Lastly, while CPC implementation was temporally associated with improved outcomes, other concurrent improvements in the healthcare system—such as enhanced access to interventional services, availability of new medications, and better provider training-may also have contributed. Although baseline characteristics were generally balanced between groups, we did not systematically capture changes in healthcare infrastructure over time, leaving residual confounding possible.

The findings of this study strongly advocate for the expansion of CPC networks across China to standardize care for STEMI patients. Policymakers should prioritize investments in CPC and incentivize hospitals to adopt evidence-based protocols. Public awareness campaigns and training programs for healthcare professionals are essential to maximize the impact of CPC, particularly in underserved areas. Moreover, leveraging digital health tools, such as telemedicine and artificial intelligence, could further enhance the efficiency and accessibility of CPC systems.