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Background Prehospital delays remain critical barriers to timely acute coronary syndrome (ACS) care, particularly for patients referred from resource-constrained primary healthcare to hospitals with percutaneous coronary intervention (PCI) capabilities. This study evaluated the associations between China Chest Pain Unit (CPU) programme, with prehospital delays, management and in-hospital outcomes for ACS patients.Methods This retrospective cohort study used registry data from the Chinese Cardiovascular Association Database. We included patients diagnosed with ACS who were referred from primary healthcare facilities to chest pain centres (CPCs). The CPU-referral group received standardised triage and referral protocols; the non-CPU-referral group received routine referral. All patients were treated at CPCs. Primary outcomes included in-hospital heart failure, in-hospital mortality, door-in-door-out (DIDO) time and time from onset to CPC door. Secondary outcomes included time from onset to first medical contact, door-to-balloon time, discharge medication use, length of stay and total hospital expenditure. Propensity score matching and generalised linear mixed models were used to evaluate the associations.Results A cohort consisting of 8834 patients was constructed by propensity score matching among 119 723 eligible referred ACS patients (5000 CPU-referrals and 114 723 non-CPU-referrals). CPU referral was associated with lower odds of in-hospital heart failure (OR 0.16, 95% CI 0.08 to 0.30) and in-hospital mortality (OR 0.68, 95% CI 0.50 to 0.92), shorter DIDO time (β=−0.33, 95% CI −0.40 to −0.25) and shorter times from onset to arrival at the CPC door (β=−0.19, 95% CI −0.27 to −0.11). CPU referral was also associated with shorter time to first medical contact and door-to-balloon time, improved adherence to guideline-recommended discharge medications, reduced length of stay and lower total hospital expenditure.Conclusions The regionalised quality improvement programme for CPUs was associated with reduced prehospital delays, lower in-hospital heart failure and mortality, better care quality and lower costs among referred ACS patients.