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Objectives To examine whether longer holidays are associated with worse quality of care for patients with ST-segment elevation myocardial infarction (STEMI) compared with weekday admissions and to evaluate the impact of holiday duration on both process indicators and mortality outcomes.Design Retrospective observational study.Setting Nationwide study across 3278 hospitals in China participating in the China Cardiovascular Association Database-Chest Pain Centre Registry.Participants A total of 616 382 STEMI episodes from 1 January 2016 to 31 December 2021 were included.Primary and secondary outcome measures Primary outcome was in-hospital mortality. Secondary outcomes included process indicators: initial ECG acquisition within 10 min, thrombolytic treatment within 30 min and door-to-balloon time within 90 min. Admissions were categorised as weekday (reference), weekend, short-term holiday (3–5 days) or long-term holiday (7–10 days).Results Long-term holidays were associated with a 10% increased risk of in-hospital mortality (OR=1.10, 95% CI: 1.02 to 1.18, p<0.05), with a 17% increased risk during the Spring Festival (OR=1.17, 95% CI: 1.09 to 1.25, p<0.01). Weekends showed a 5% increased mortality risk (OR=1.05, 95% CI: 1.02 to 1.09, p<0.01). Initial ECG acquisition within 10 min improved during long-term holidays (OR=1.15, 95% CI: 1.10 to 1.21, p<0.001). However, short-term holidays were associated with worse performance for thrombolytic treatment within 30 min (OR=0.83, 95% CI: 0.76 to 0.91, p<0.01) and door-to-balloon time within 90 min (OR=0.83, 95% CI: 0.80 to 0.87, p<0.01). Primary-secondary hospitals showed lower odds of timely percutaneous coronary intervention during long-term holidays (OR=0.83, 95% CI: 0.75 to 0.92, p<0.001), while tertiary hospitals were more affected during short-term holidays (OR=0.82, 95% CI: 0.79 to 0.86, p<0.001).Conclusions Longer holidays, particularly the Spring Festival, are associated with slightly worse outcomes for patients with STEMI in China. While initial assessments may be expedited during holidays, delays occur in providing definitive treatment. These findings highlight the need for targeted strategies to maintain high-quality STEMI care during extended holiday periods.