Background
Acute coronary syndrome (ACS) is a significant contributor to both morbidity and mortality in Australia. Generally speaking, sufferers of ACS who live in rural areas and are treated at rural hospitals have poorer outcomes than those living in metropolitan areas.

Aims
To characterise the differences in the management and outcomes of rural and metropolitan populations in the context of ACS, as well as identify factors responsible for these differences and suggest how they may be addressed.

Method
A review of the current literature surrounding ACS in Australia was undertaken. Through the MEDLINE/PubMed database a thorough search using the terms “acute coronary syndrome” and “Australia” identified 460 papers for review, excluding abstracts and adding “rural”, “metropolitan”, “reperfusion”, and “outcomes” to this search narrowed the results to 149 papers for review. Data was also extracted from the Australian Institute of Health and Welfare and other Australian government publications. The review draws on insights from both local and international resources and seeks to provide an understanding of the contemporary landscape of ACS in both rural and metropolitan Australia. 

The review is broken down into three key sections:

1. An outline of the 2011 National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guidelines and adjuvant tools used in the assessment and treatment of ACS, and to what extent these guidelines have been implemented clinically.

2. An exploration of the current landscape of ACS in Australia and identification of the disparities facing rural populations compared to those in metropolitan areas.

3. Discussion of the factors that are resulting in poorer outcomes for ACS sufferers and suggestions of novel approaches towards addressing these factors.

Conclusion
Disparities exist between the management and outcomes of rural and metropolitan populations experiencing ACS. While the causes of these discrepancies are multifactorial, the onus is on the healthcare system to effectively reduce associated morbidity and mortality. Improvements in the management of ACS may be achieved through a continued reduction in call-to-needles time via the use of remote and mobile thrombolysis services as well as improvements in in-hospital risk assessment in order to flag and investigate those at risk of ACS.