Despite improvements in acute coronary syndrome (ACS) care over several decades, outcomes for Indigenous Australians remain worse than non-Indigenous Australians. Access to care has been a suggested contributing factor. To determine access to guideline-recommended ACS (GR-ACS) treatment for patients admitted to Royal Darwin Hospital (RDH). A retrospective audit of all first-presentation ACS admissions to RDH between January 2016 and July 2017 was performed. Data collected included demographics, comorbidities, treatment and 12-month outcomes. 288 patients including 111 (39%) Indigenous patients were reviewed. Indigenous patients were younger than their non-Indigenous counterparts (48 vs 61 years; p<0.01) with greater burden of comorbidities including diabetes (39% vs 19%; p<0.01), smoking (64% vs 38%; p<0.01) and chronic kidney disease (29% vs 5%; p<0.01). There were no differences in access to coronary angiography (97% vs 95%; p=0.43) or percutaneous intervention (47% vs 57%; p=0.12). Prescribed GR-ACS medication rates were similar for dual antiplatelet therapy (86% vs 88%; p=0.53), statins (91% vs 90%; p=0.10) and beta blockers (74% vs 72%; p=0.77). There were no differences in 30-day mortality (2% vs 2%; p=0.79), 12-month ACS readmissions (7% vs 3%; p=0.14) or 12-month cardiac-related readmissions (7% vs 14%; p=0.1). These results suggest no differences in inpatient ACS care or secondary prevention at time of discharge, between Indigenous and non-Indigenous Australians admitted to RDH. Similar outcomes up to 12 months post-ACS and differences in baseline cardiovascular risk factors requires confirmation with a larger sample size and compels consideration of other primary and secondary prevention contributors.