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Background Timely reperfusion in STEMI is crucial for improving outcomes. The 2023 ESC Guidelines recommend PCI within 90 minutes of diagnosis, or thrombolysis within 10 minutes when PCI is not possible within 120 minutes. Delayed reperfusion can significantly affect mortality and left ventricular function.Objectives This audit aimed to identify the causes of delayed reperfusion in STEMI patients at St. James’s Hospital, using ESC standards as benchmarks, and assess associated outcomes such as mortality and left ventricular ejection fraction (LVEF).Methods A retrospective audit of STEMI patients presenting to St. James’s Hospital from January to December 2024 was conducted. Delays were categorized according to ESC guidelines into four groups: (1) thrombolysis delay (triage-to-needle >20 minutes), (2) pre-hospital delay (ambulance arrival to first ECG), (3) diversion to district hospitals, and (4) inter-hospital transfer delays. The primary outcomes were 30-day mortality and LVEF.Results Among 404 STEMI patients, 151 (37.4%) experienced delayed reperfusion. Causes of delay included transport delays (34.5%) and delayed diagnosis (21.2%). PCI was performed in 84.8% of cases, with a mean reperfusion time of 182.7 minutes. Severe left ventricular dysfunction (LVEF ≤35%) was seen in 26.5% of delayed cases. Mortality was 8.6%, with no significant association between delay causes and death (p=0.638).Conclusions Delayed reperfusion is common and frequently caused by pre-hospital and systemic factors. The audit highlights the need for improvements in early diagnosis, EMS coordination, and inter-hospital processes. Further analysis of additional cases will guide targeted interventions to reduce delays and improve outcomes.