Objective: The primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for ST-segment elevation myocardial infarction (STEMI). The pharmacoinvasive strategy (PIs) is a reasonable alternative when prompt PPCI is not possible, especially in resource-limited regions. We aimed to compare PPCI versus PIs outcomes in Peru. Methods: This was a retrospective cohort study based on the second Peruvian Registry of STEMI (PERSTEMI II). We compared the characteristics, in-hospital outcomes and 30-day mortality of patients undergoing PPCI during the first 12 h and those receiving a PIs. A propensity score-matched analysis was conducted to compare the effects of each treatment strategy on clinical outcomes. Results: PIs patients were younger than PPCI patients, had a shorter first medical contact time, first medical contact to reperfusion time, and total ischemic time until reperfusion. Successful PCI was more frequent in the PIs group (84.4% vs. 71.1%, p = 0.035). There were no differences between PIs and PPCI in terms of total in-hospital mortality (5.2% vs. 6.6%, p = 0.703), cardiovascular mortality (4.2% vs. 5.3%, p = 0.735), cardiogenic shock (8.3% vs. 13.2%, p = 0.326), heart failure (19.8% vs. 30.3%, p = 0.112), or major bleeding (0% vs. 2.6%, p = 0.194). In the propensity score-matched analysis, the rates of cardiovascular mortality, postinfarction heart failure and successful reperfusion were similar. Conclusions: In this real-world study, no differences were found in the in-hospital outcomes between patients with STEMI who received PIs or PPCI.