Background: ST-segment elevation myocardial infarction (STEMI) remains a major contributor to global cardiovascular mortality, particularly in lower-middle-income countries. Contemporary longitudinal data describing trends and outcomes of STEMI in Sri Lanka remain limited.

Methods: This multicentre observational study analysed data from a prospective electronic acute myocardial infarction registry at the National Hospital of Sri Lanka, Colombo, and Jaffna Teaching Hospital. Adults with confirmed STEMI were included, and temporal trends in admissions, demographics, comorbidities, reperfusion metrics, and in-hospital mortality were assessed.

Results: A total of 5,955 STEMI patients were included. The cohort was predominantly male (82.5%), with a median age of 55 years (IQR 46–63). STEMI admissions increased overall, with a transient decline during the COVID-19 pandemic. The proportion of patients aged ≥60 years increased from 27.6% to 37.5%, alongside rising cardiometabolic comorbidity and multimorbidity. Among patients undergoing primary percutaneous coronary intervention, the median door-to-balloon time was 104 minutes, with only 40.8% achieving guideline-recommended targets. Overall in-hospital mortality was 2.7%, declining from 6.5% in 2018 to 0.6% in 2023. Increasing age, diabetes mellitus (OR 1.79, 95% CI 1.19–2.73), and prior myocardial infarction (OR 2.16, 95% CI 0.95–4.41) were independently associated with higher mortality.

Conclusions: Despite increasing comorbidity burden and persistent reperfusion delays, in-hospital mortality among STEMI patients declined substantially over six years in these tertiary centres. System-level improvements in prehospital triage and coordinated STEMI care networks may have contributed to these favourable outcomes. Continued investment in timely reperfusion and chronic disease management is essential to sustain gains in STEMI care in Sri Lanka.

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