Objectives To assess differences in reperfusion treatment and outcomes between secondary and tertiary hospitals in predominantly rural central China.Design Multicentre, prospective and observational study.Setting Sixty-six (50 secondary and 16 tertiary) hospitals in Henan province, central China.Participants Patients with ST elevation myocardial infarction (STEMI) within 30 days of symptom onset during 2016–2018.Primary outcome measures In-hospital mortality, and in-hospital death or treatment withdrawal.Results Among 5063 patients of STEMI, 2553 were treated at secondary hospitals. Reperfusion (82.0% vs 73.0%, p