Background: Primary percutaneous coronary intervention (PCI) is the gold standard reperfusion strategy for ST-elevation myocardial infarction (STEMI), provided it is delivered within guideline-recommended time frames. However, in low- and middle-income countries (LMICs) such as Bangladesh, there is marked heterogeneity in the availability and quality of PCI services, with a concentration of catheterization laboratories and interventional cardiologists in major urban centers. This urban–rural divide may translate into differences in clinical outcomes, but empirical data from Bangladesh remain sparse.Objective: This study compares short-term outcomes of primary PCI performed in rural versus urban hospitals in Bangladesh, focusing on mortality, major adverse cardiovascular events (MACE), and process indicators such as door-to-balloon time and guideline adherence.Methods: We conducted a multicenter retrospective observational study of 1,200 consecutive STEMI patients undergoing primary PCI across eight hospitals (five urban tertiary centers and three rural or semi-urban PCI-capable hospitals) between January 2021 and December 2023. Primary outcome was in-hospital all-cause mortality. Secondary outcomes included 30-day mortality, in-hospital MACE (re-infarction, stroke, urgent revascularization), contrast-induced nephropathy, heart failure, stent thrombosis, and length of stay. Door-to-balloon time, total ischemic time, and pharmacological therapy at discharge were also assessed. Multivariable logistic regression was used to adjust for baseline demographic and clinical differences.Results: Of the 1,200 patients, 780 (65%) were treated in urban and 420 (35%) in rural hospitals. Rural patients presented later (median symptom-onset-to-door time 260 vs. 180 minutes) and had longer median door-to-balloon time (95 vs. 70 minutes). Crude in-hospital mortality was higher in rural hospitals (7.6% vs. 4.1%, p = .02) and 30-day mortality was 9.8% vs. 5.5% (p = .01). After adjustment for age, Killip class, diabetes, and total ischemic time, rural hospital primary PCI remained associated with higher odds of in-hospital mortality (adjusted OR 1.72, 95% CI 1.03–2.86). Prescription of guideline-directed secondary prevention (dual antiplatelet therapy, statins, ACEI/ARB, beta-blockers) was lower in rural centers.Conclusion: In Bangladesh, patients undergoing primary PCI in rural hospitals experienced worse early outcomes compared to those treated in urban centers, driven largely by delays in presentation, longer door-to-balloon times, and lower adherence to guideline-based therapies. Strengthening referral networks, improving pre-hospital care, and upgrading capacity in rural PCI centers are essential to reduce inequities in STEMI outcomes.