OBJECTIVE(S): To assess differences in inpatient access to guideline-recommended acute coronary syndrome (GR-ACS) treatment for Aboriginal and Torres Strait Islander and non-indigenous patients admitted to Royal Darwin Hospital (RDH) with index ACS event. DESIGN, SETTING AND PARTICIPANTS: Retrospective audit of index ACS admissions to RDH between January 2016 - June 2017. MAIN OUTCOME MEASURES: Rates of coronary angiography, percutaneous coronary intervention (PCI), surgical revascularisation, GR- ACS medications prescribed on discharge and short-term outcomes (30-day mortality and ACS readmissions; 12-month all cardiac-related readmissions) RESULTS: 288 patients, including 109 (37.85%) Aboriginal and Torres Strait Islander patients, were included. Compared to non-indigenous patients, they were younger (median age 48 years vs 60 years; p<0.01), with a greater burden of comorbidities including diabetes (38.53% vs 18.99%; p<0.01), smoking (67.89% vs 34.64%; p<0.01) and chronic kidney disease (29.36% vs 5.03%; p<0.01). There were no differences in rates of coronary angiography (98.17% vs 95.53%; p=0.24) or PCI (47% vs 57%; p=0.12), although there was a trend towards surgical revascularisation in Aboriginal and Torres Strait Islander patients (16% vs 8%; p=0.047). There were no differences in 30-day mortality (1.83% vs 1.68%; p=0.72), 12-month ACS readmissions (7.34% vs 3.91%; p=0.20) or 12-month cardiac-related readmissions (7.34% vs 13.41%; p=0.11). CONCLUSIONS: Aboriginal and Torres Strait Islander patients received similar inpatient ACS care and secondary prevention medication at discharge, with similar short-term mortality outcomes as non-indigenous patients. Differences in long-term cardiovascular outcomes and baseline cardiovascular risk factors compel consideration of other primary and secondary prevention contributors. This article is protected by copyright. All rights reserved.