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The goal of the updated guideline is to ensure that clinicians are supported by the best evidence-based recommendations available, to provide the best possible outcomes for people with acute coronary syndromes.
When someone calls triple zero (000), every minute counts. Acute coronary syndromes (ACS), most commonly unstable angina and acute myocardial infarction, still claim more than 17 000 deaths annually in Australia. Despite declining age-standardised rates of ACS, inequities persist for women, First Nations peoples, and people living outside major cities. Against this backdrop, the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand have released the first full ACS guideline update since 2016, providing contemporary, evidence-based recommendations across the care continuum.
An ACS episode marks the beginning of a lifelong health journey requiring coordinated care from emergency response and hospital treatment to long term secondary prevention. While timely, evidence-based care improves outcomes for many, others experience gaps in follow-up or recurrent events. This guideline aims to support clinicians with up-to-date, evidence-informed guidance in delivering optimal care at every stage.
Three main factors necessitated an update. First, advances in diagnostic technologies such as high-sensitivity cardiac biomarkers, intravascular imaging and functional invasive testing have reshaped how coronary events are assessed and understood. Second, robust evidence shows that timely reperfusion, tailored secondary prevention and person-centred care reduce mortality and recurrent events, and improve quality of life. Third, persistent inequities affecting underserved populations call for practical, culturally appropriate guidance. Therefore, the guideline introduces clearer terminology, streamlines pathways and embeds culturally appropriate, shared decision-making principles throughout.
A new definition for myocardial infarction
A major conceptual change is the revised definition of myocardial infarction (MI), which more clearly distinguishes between atherosclerotic and non-atherosclerotic causes, previously classified as type 1 and type 2 MI respectively. The guideline also introduces the term acute coronary occlusion myocardial infarction (ACOMI) to highlight ST-segment elevation myocardial infarction (STEMI) equivalents that are often under-recognised in acute settings and require close monitoring for indications for emergency reperfusion.
Modern day refining of assessment and diagnosis
Early risk stratification hinges on precise ECG interpretation and the use of assay-specific troponin algorithms. The guideline describes a spectrum of ACOMI ECG patterns beyond the standard ST-segment elevation criteria and recommends that all patients with suspected ACS receive a 12-lead ECG within 10 minutes of first medical contact to assess for ACOMI. Serial high-sensitivity cardiac troponin measurements, using assay-specific and sex-specific thresholds, now underpin accelerated decision pathways capable of safely ruling in or ruling out MI within three hours.
For patients classified as intermediate risk using a validated clinical decision pathway, invasive coronary angiography or computed tomography coronary angiography is recommended in those without previously known coronary artery disease to clarify prognosis beyond 30 days.
Optimising hospital care and reperfusion
Time-critical reperfusion is central to limiting myocardial injury. Updated benchmarks for primary percutaneous coronary intervention (PCI) in patients with STEMI are less than 60 minutes from first medical contact at PCI-capable hospitals and less than 90 minutes for those presenting to non-PCI centres. New evidence supports intravascular imaging-guided PCI in non-ST-segment elevation ACS (NSTEACS) to improve stent optimisation and reduce future events. Where PCI within 120 minutes is not possible in some settings, an alternative thrombolysis protocol is provided.
The guideline also addresses the management of ACS complicated by cardiac arrest or cardiogenic shock, including indications for mechanical circulatory support and left-ventricular assist devices. For STEMI with multivessel disease, PCI of non-infarct-related arteries (non-IRAs) should occur either during the index admission or within 19 days. In NSTEACS with multivessel disease, fractional flow reserve may guide revascularisation decisions for non-IRAs. Selective management is outlined for spontaneous coronary artery dissection, emphasising conservative management when haemodynamics permit.
Strengthening recovery and secondary prevention
Post-hospital care is a key focus of the guideline. Clinicians are urged to initiate comprehensive discharge planning covering guideline-directed pharmacotherapy, adherence support, vaccination against respiratory pathogens, mental health screening and referral to cardiac rehabilitation.
The recommended low-density lipoprotein cholesterol target is now < 1.4 mmol/L, with at least a 50% reduction from baseline, aligning with international guidelines. New treatment algorithms facilitate nuanced selection and adjustment of antiplatelet and anticoagulant therapies, balancing ischaemic and bleeding risks. The guideline also clarifies the role of beta-blockers and recommends PCSK9 inhibitors for very high risk patients not achieving lipid targets despite maximally tolerated statins and ezetimibe.
Embedding equity and shared decision making
Consistent with the National Closing the Gap strategy and Australian Commission on Safety and Quality in Health Care Standards, the guideline embeds practice points for women, older adults, First Nations peoples, and regional and remote populations. These include using culturally appropriate communication tools, telehealth pathways for rapid ECG interpretation, and strategies that minimise treatment delays caused by inter-hospital transfers. Shared decision making is promoted as standard practice, and clinicians are encouraged to engage Aboriginal liaison officers and accredited interpreters early in the care journey.
The way forward
Translating these recommendations into practice will require coordinated efforts from health services, professional colleges and policy makers. The guideline re-affirms that every minute counts in ACS diagnosis and management. By integrating the latest evidence, embracing emerging technologies and prioritising person-centred care, the guideline offers a pragmatic roadmap to further reduce the burden of ACS. Clinicians implementing these recommendations, with a focus on addressing persisting inequities, will determine whether Australia sustains its hard-won gains and realises the full potential of modern ACS care.
The full guideline can be found at Australian clinical guideline for diagnosing and managing acute coronary syndromes 2025.
Professor Garry Jennings AO is Chief Medical Advisor of the Heart Foundation, a cardiologist at the Baker Institute where he was Director and CEO of from 2001–15, and Honorary Professor of Medicine at the University of Sydney and Monash. He was Deputy Chair of the Global Cardiovascular Research Funders Forum.
Dr Dannii Dougherty is Clinical Evidence manager at the Heart Foundation, an affiliate associate lecturer in the School of Public Health at the University of Adelaide and has taught evidence-based practice and systematic review methodology at the University of South Australia.
With more than a decade of experience in evidence-based medicine, guideline methodology and knowledge translation, Dr Dougherty holds a PhD in Medicine and advocates for rigorous, transparent evidence to strengthen cardiovascular care and policy across Australia.
Elaine Ho is Senior Evidence and Policy Advisor at the Heart Foundation, and project leads the acute coronary syndromes guideline update. She is also an Accredited Practising Dietitian with extensive Australian and international experience in evidence review, knowledge translation and healthcare management.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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