Aims In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities. Methods and results The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay − transport time) decreased by 40% (95% confidence intervals: −66%, −13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin 94.2–100% (P = 0.003) and P2Y12 inhibitors 87.5–100% (P < 0.001). The odds of in-hospital death showed a non-significant decrease odds ratio 0.73 (95% confidence intervals: 0.34–1.60). Conclusion The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.