CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 AFRICA 143 follow up and interventions, such as PCI, as well as high rates of non-adherence to prescribed guideline-directed therapy. High rates of recurrence will continue to place additional strain on the already overburdened public healthcare services. Limitations There were several limitations of this study. The retrospective nature of this study limited access to detailed and complete clinical data, such as the timing of STEMI diagnosis and implemented reperfusion interventions, as well as associated in-hospital outcomes. As a result, we were unable to assess the effect of variables such as time from FMC to ECG diagnosis, and door-to-reperfusion time. We acknowledge that these variables would serve as more reliable indicators of quality of care in this context and we therefore recommend that a prospective database of STEMI referral and management data be implemented to facilitate further assessment and optimisation of STEMI management. Despite the inclusion of all patients who presented to the emergency unit with ACS, the sample size remained small. As a result, sub-analyses in this study should be interpreted with caution and the generalisability of the study findings is limited. Conclusions To the best of our knowledge, this study is among the first to report the profile of patients with ACS treated in the South African public healthcare sector. This study highlights several challenges faced in the management of ACS in this context, such as high prevalence of cardiovascular risk factors and rates of non-adherence to chronic medication, significantly delayed FMC, insufficient ECG diagnostic proficiency, the absence of a dedicated ACS referral network, as well as high rates of recurrence of ACS within one year of the index presentation. Thrombolysis is often not offered to those with STEMI, due to delayed presentation or missed ECG diagnosis. To address the challenges identified in our study, we propose the establishment of an improved regional referral network for ACS in our public health system. This network should prioritise early identification of patients requiring reperfusion and facilitate rapid referral from primary- and secondarylevel healthcare facilities to PCI-capable tertiary centres. The goal of this network would be to improve patient access to appropriate primary reperfusion interventions. 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