Introduction The use of an out-of-hospital 12-lead electrocardiograph (ECG) has long been the salient test used when assessing ischaemic chest pain and is the only clinical tool available to paramedics that allows for early diagnosis and triage of acute coronary syndromes. This ultimately indicates whether urgent percutaneous coronary intervention is indicated. Therefore, the ability to apply and interpret a 12-lead ECG are key skills for paramedics with potentially significant effect on patient outcomes. This study’s objective was to review and summarise existing literature pertaining to the ability of paramedics to correctly identify STEMI via 12-lead ECGs. Methods Ovid Medline, Ovid Emcare and CINAHL Plus were all searched using synonyms of keywords such as paramedic, ECG, diagnosis and STEMI. Two investigators independently screened the titles, abstracts and full texts of the articles against the inclusion and exclusion criteria. Any conflicts that arose were discussed between the two investigators to meet consensus. Results Of the 2126 articles initially identified, nine studies were relevant and examined the ability of paramedics to identify STEMI on out-of-hospital ECGs. Results indicated that increased additional education provided to paramedics, and the implementation of protocols and/or tools demonstrated a higher degree of accuracy regarding STEMI recognition. Conclusion Seven of the nine articles had a strong general consensus that paramedics can independently interpret 12-lead ECGs in order to identify STEMI, however not all studies were of good quality. The importance of the pre-hospital ECG in the setting of STEMI is well established, however the ability of paramedics to independently interpret them requires further study.