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Aims To assess the level of evidence-based drug prescribing for acute coronary syndrome ( ACS) at discharge from Western Australian ( WA) hospitals and determine predictors of such prescribing in Aboriginal and non- Aboriginal patients. Methods All Aboriginal (2002-2004) and a random sample of non-Aboriginal (2003) hospital admissions with a principal diagnosis of ACS were extracted from the WA Hospital Morbidity Data Collection of WA Data Linkage System. Clinical information, history of co-morbidities and drugs were collected from medical notes by trained data collectors. Evidence-based prescribing ( EBP) was defined as prescribing of aspirin, statin and beta-blocker or angiotensin-converting enzyme inhibitor/angiotensin II antagonist. Results Records for 1717 ACS patients discharged alive from hospitals were reviewed. The majority of patients (71%) had EBP, and there was no significant difference between Aboriginal and non- Aboriginal patients (70% vs 71%, P = 0.36). Conversely, a significantly higher proportion of Aboriginal patients had none of the drugs prescribed compared with non- Aboriginal patients (11% vs 7%, P < 0.01). EBP for ACS was independently associated with male sex (odds ratio ( OR) 1.63, 95% confidence interval ( CI) 1.26−2.11), previous admission for ACS ( OR 1.83, 95% CI 1.39-2.42) and diabetes ( OR 1.36, 95% CI 1.04-1.79). However, ACS patients living in regional and remote areas, attending district or private hospitals, or with a history of chronic obstructive pulmonary disease were significantly less likely to have ACS drugs prescribed at discharge. Conclusions Opportunity exists to improve prescribing of recommended drugs for ACS patients at discharge from WA hospitals in both Aboriginal and non- Aboriginal patients. Attention regarding pharmaceutical management post- ACS is particularly required for patients from rural and remote areas, and those attending district and private hospitals. [ABSTRACT FROM AUTHOR]