Acute Coronary Syndromes Clinical Care Standard
The Acute Coronary Syndromes Clinical Care Standard is intended to ensure that a patient with an ACS receives the best treatment from the onset of symptoms through to discharge from hospital. This includes recognition of an ACS, rapid assessment, early management and early initiation of a tailored rehabilitation plan, to maximise the patient’s chances of recovery, and reduce their risk of a future cardiac event.
What is an acute coronary syndrome?
An acute coronary syndrome (ACS) results from a sudden blockage of a blood vessel in the heart, typically by a blood clot (thrombosis) that reduces blood supply to a portion of heart muscle. If the blockage is severe enough to lead to injury or death of the heart muscle, the event is called an acute myocardial infarction (or heart attack).
Acute coronary syndromes include ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (chest pain usually due to restricted blood flow to the heart muscle), which can lead to a heart attack.
The most common cause of an ACS is atherosclerosis (or coronary heart disease), in which an artery wall thickens as a result of a build-up of fatty materials such as cholesterol.
About the Standard
The Acute Coronary Syndromes Clinical Care Standard was first published in 2014 and last reviewed against the guidelines in 2019.
The Standard includes:
- Six quality statements describing safe and appropriate care
- A set of indicators to support monitoring and quality improvement
We also have resources for clinicians, healthcare services and consumers to support the implementation of the Acute Coronary Syndromes Clinical Care Standard.
Quality Statements
Quality statement 1 – Immediate management
A patient presenting with acute chest pain or other symptoms suggestive of an acute coronary syndrome receives care guided by a documented chest pain assessment pathway.
For clinicians
Use a documented chest pain assessment pathway to provide care to all patients who present with symptoms of an ACS. Ensure that your patients understand what is happening and why.
For healthcare services
Ensure that a chest pain assessment pathway is available and used consistently by clinicians. A chest pain assessment pathway taken from the national guideline is available from the Heart Foundation1.
For consumers
Ensure that a chest pain assessment pathway is available and used consistently by clinicians. A chest pain assessment pathway taken from the national guideline is available from the Heart Foundation1.
Quality statement 2 – Early assessment
A patient with acute chest pain or other symptoms suggestive of an acute coronary syndrome receives a 12-lead electrocardiogram (ECG), and the results are analysed by a clinician experienced in interpreting an ECG within 10 minutes of the first emergency clinical contact.
For clinicians
Assess all patients with a suspected ACS with a 12-lead ECG, and interpret the results within 10 minutes of the first emergency clinical contact. This may involve facilitating referral to a clinician experienced in performing or interpreting an ECG.
For healthcare services
Ensure that systems and processes are in place in the pre-hospital and hospital settings to assess patients with symptoms of an ACS using a 12-lead ECG, and for the ECG to be analysed by a clinician experienced in interpreting an ECG within 10 minutes of the first emergency clinical contact.
For consumers
If you have chest pain or other symptoms that could indicate a heart attack, you will have an ECG as soon as possible. The ECG should be interpreted within 10 minutes so that any necessary emergency treatment can be provided.
Quality statement 3 – Timely reperfusion
A patient with an acute ST-segment-elevation myocardial infarction (STEMI), for whom emergency reperfusion is clinically appropriate, is offered timely percutaneous coronary intervention (PCI) or fibrinolysis in accordance with the time frames recommended in the current National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes. In general, primary PCI is recommended if the time from first medical contact to balloon inflation is anticipated to be less than 90 minutes; otherwise, the patient is offered fibrinolysis.
For clinicians
Offer primary PCI or fibrinolysis to all eligible patients diagnosed with an acute STEMI, within the time frames recommended in the current Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes. Ensure that the patient understands the risks and benefits of their proposed treatment, and provides their consent.
For healthcare services
Ensure that systems and processes are in place for clinicians to offer primary PCI or fibrinolysis to all eligible patients diagnosed with an acute STEMI within the time frames recommended in the current Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes.
For consumers
If you have a heart attack in which the artery supplying an area of the heart muscle is completely blocked, your doctor decides whether you can have a procedure called PCI. In a PCI, a heart specialist passes a fine probe through an artery to your heart and inflates a small balloon that aims to ease the blockage. If a PCI cannot be provided within an appropriate time frame, you may be given a medicine that dissolves blood clots. This is done urgently. Your doctor will discuss your treatment with you so that you understand the risks and benefits, and can provide your consent.
Indicators
Quality statement 4 – Risk stratification
A patient with a non-ST-segment-elevation acute coronary syndrome (NSTEACS) is managed based on a documented, evidence-based assessment of their risk of an adverse event.
For clinicians
Use an evidence-based risk assessment tool to stratify the patient’s risk of future cardiac events. Discuss the identified level of risk with the patient, and use a shared decision making process to plan their treatment based on their risk of an adverse event and their treatment preferences.
Risk assessment tools include:
- GRACE ACS Risk Calculator2
- TIMI Risk Score for UA/NSTEMI3
- Decision making and timing considerations in reperfusion for STEMI.4
For healthcare services
Ensure that an evidence-based risk assessment process is available to guide the treatment of all patients with an NSTEACS, and that clinicians use it consistently.
For consumers
If you have a heart attack in which the artery supplying an area of the heart muscle is partly but not fully blocked, your treatment will depend on your risk of having a serious heart problem in the future. Your doctor will discuss your individual level of risk with you, and work with you to make sure you have the information you need to make choices about your treatment.
Quality statement 5 – Coronary angiography
The role of coronary angiography, with a view to timely and appropriate coronary revascularisation, is discussed with a patient with a non-ST-segment-elevation acute coronary syndrome (NSTEACS) who is assessed to be at intermediate or high risk of an adverse cardiac event.
For clinicians
If patients are identified to be at intermediate or high risk of an adverse cardiac event, discuss with them the risks and benefits of coronary angiography and appropriate revascularisation.
For healthcare services
Ensure that systems and processes are in place for clinicians to offer coronary angiography and appropriate coronary revascularisation to all eligible patients with an NSTEACS.
For consumers
If you have a heart attack in which the artery supplying an area of the heart muscle is partly but not fully blocked, your doctor works out your risk of having a serious heart problem in the future.
If that risk is medium or high, your doctor talks to you about whether you should have a procedure called coronary angiography. In coronary angiography, a specialist passes a fine probe through an artery to your heart, then releases a dye that shows up on X-rays. In this way, your doctors know which arteries are blocked, and how much they are blocked. Then they talk to you about whether it is possible to unblock them, and how best to do so.
Quality statement 6 – Individualised care plan
Before a patient with an acute coronary syndrome leaves the hospital, they are involved in the development of an individualised care plan. This plan identifies the lifestyle modifications and medicines needed to manage their risk factors, addresses their psychosocial needs and includes a referral to an appropriate cardiac rehabilitation or another secondary prevention program. This plan is provided to the patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.
For clinicians
Develop an individualised care plan with each patient with an ACS before they leave the hospital. The plan identifies lifestyle changes and medicines, addresses the patient’s psychosocial needs and includes a referral to an appropriate cardiac rehabilitation or other secondary prevention program. Provide a copy of the plan to the patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.
For healthcare services
Ensure that processes are in place so that clinicians can develop an individualised care plan with patients with an ACS before they leave the hospital, and provide the plan to each patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.
For consumers
Before you leave the hospital, your doctors and nurses discuss your recovery with you. They help develop a plan with you that sets out:
- what changes you may need to make to your lifestyle
- what medicines you may need to take
- what rehabilitation clinic or prevention service you are referred to.
You and your regular general practitioner get a copy of this plan within two days after you leave hospital.
Indicators
Indicators
The Commission has developed a set of indicators to support clinicians and healthcare services to monitor how well they are implementing the care recommended in this Clinical Care Standard. The indicators are intended to support local quality improvement activities. No benchmarks are set for these indicators by the Commission.
When using the indicators, please refer to the definitions required to collect and calculate indicator data which are specified online at METEOR.
You can find a description of each indicator below with links to its individual specifications.
List of indicators
Cultural safety and equity for Aboriginal and Torres Strait Islander peoples
Health outcomes for Aboriginal and Torres Strait Islander peoples can be improved by addressing systemic racism and other root causes that reduce access to care. Historical and current contributing factors include a lack of culturally safe care, culturally appropriate health education and sociocultural determinants such as differences in employment opportunities.
The considerations for improving cultural safety and equity in this Clinical Care Standard focus primarily on overcoming cultural power imbalances and improving outcomes for Aboriginal and Torres Strait Islander people through better access to health care
Cultural safety and equity recommendations in this document have been developed in consultation with Aboriginal and Torres Strait Islander individuals, clinicians and representative health service organisations. However, it is recognised that cultural safety is determined by the Aboriginal and Torres Strait Islander individuals, families and communities experiencing the care.
Recommendations
When implementing this Clinical Care Standard, cultural safety can be improved through embedding an organisational approach such as described in the recommendations below. Specific considerations for cultural safety for people undergoing colonoscopy are provided throughout this Standard.
When providing care for Aboriginal and Torres Strait Islander people, particular consideration should be given to the following recommendations.
Building culturally safe systems
- Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
- Ensure all staff engage regularly in cultural safety training.
- Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.
Flexible and connected service delivery
- Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
- Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
- Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.
Communication and person-centred care
- Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
- Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
- Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
- Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
- Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.
Resource hub
Implementation resources are resources developed by the Commission that will assist in implementing and understanding the Clinical Care Standards. They include short guides to the Standards for consumers, clinicians and healthcare services, and other tools and resources to support implementation.
Related resources are other resources that the Commission has identified as relevant and useful. Most often, these come from sources outside the Commission. They may include additional information, guidelines, tools and consumer materials.
The resources below have been developed to support clinicians to implement the care described in the Standard.
The Commission has developed the Consumer fact sheet to help people with an acute coronary syndromes and their support people to understand the care they can expect to be offered.
More about the Standard
What is the background to the Standard?
While there are well-developed guidelines for managing acute coronary syndromes, not all people receive appropriate treatment and there is variation in the type of care received across Australia. Coronary heart disease (the main cause of acute coronary syndromes) kills more people in Australia than any other disease.
Read more about the scope and goal of this Standard or see further background in the Acute Coronary Syndromes Clinical Care Standard.
Where does the Standard apply?
This Standard applies to care provided in acute hospital settings, including public and private hospitals. Not all quality statements in this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement.
When implementing this Standard, healthcare services should consider:
- the context in which care is provided
- local variation
- quality improvement priorities of the individual healthcare service.
In rural and remote settings, different strategies may be needed to implement the standard. For example, the use of:
- hub‑and‑spoke models integrating larger and smaller health services and ACCHOs
- telehealth consultations
- multidisciplinary teams including allied health involvement where clinically appropriate.
This Standard relates to the care that patients with a suspected ACS receive from the onset of symptoms to the completion of their treatment in hospital. It includes patients who develop a suspected ACS while in hospital for another condition.
National Safety and Quality Health Service Standards
Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:
- National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
- National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting.
Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.
How does the Standard support cultural safety and equity?
The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians.
Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission:
- is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
- acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities
Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by:
- ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
- providing visual or written information in a language that the patient, their family and carers will understand
- providing cultural competency training for all staff
- encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
- identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.
Which key organisations have endorsed the Standard?
The Acute Coronary Syndromes Clinical Care Standard has been endorsed by five key health organisations.
- Australasian College for Emergency Medicine
- Australian College of Rural and Remote Medicine
- CRANA plus
- Heart Foundation Australia
- Royal Australasian College of Surgeons
Who was consulted on its development?
The Commission develops Clinical Care Standards taking into account:
- advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
- consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments.
The Acute Coronary Syndromes Clinical Care Standard Topic Working Group provided expert advice on the development and review of the Standard. In addition, a public consultation process was conducted with key stakeholders.
Acute Coronary Syndromes (ACS) Clinical Care Standard - Topic Working Group
The main roles of the Topic Working Group were to:
- advise on the continued scope and key components of care within the Standard
- advise on the key sources of evidence to inform the review
- advise on revisions to quality statements and supporting indicators
- recommend strategies to support the implementation of the updated Standard
- actively support raising awareness of the updated Standard.
All topic working group members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are managed in line with the Commission’s Policy on Disclosure of Interests.
What was the evidence base for this Standard?
Key evidence sources that underpin the Acute Coronary Syndromes Clinical Care Standard are clinical guidelines from the Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016.
Note that these clinical guidelines were updated in 2025. The Acute Coronary Syndromes Clinical Care Standard has not been updated against the 2025 guidelines.
The Better Cardiac Care for Aboriginal and Torres Strait Islander People project has also informed the development of the Standard. The Better Cardiac Care project provides national recommendations for better cardiac care for Aboriginal and Torres Strait Islander peoples.
Webpage references
The references below are not a complete list of references for the Standard. A full reference list is published in the Acute Coronary Syndromes Clinical Care Standard which can be downloaded here.
- National Heart Foundation of Australia. Assessment protocol for suspected ACS using point-of-care assays. NHFA; 2016.
- GRACE Centre for Outcomes Research. Global Registry of Acute Coronary Events [Internet]. Boston (MA): University of Massachusetts Medical School; 2019 [cited 2019 Apr 11].
- Antman EM. TIMI risk score for UA/NSTEMI 2019 [Internet]. MDCalc; 2019 [cited 2019 Mon dd].
- National Heart Foundation of Australia (NHFA). Decision-making and timing considerations in reperfusion for STEMI. NHFA; 2016.