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Introduction Non-ST-elevation myocardial infarction (NSTEMI) is the most common acute coronary syndrome (ACS) presentation to secondary care and carries significant morbidity and mortality. The 2023 European Society of Cardiology (ESC) guidelines recommend single antiplatelet therapy (SAPT) with early invasive coronary angiography within 24 hours for high-risk patients, rather than routine pre-treatment with dual antiplatelet therapy (DAPT) for the treatment of NSTEMI. Randomised data demonstrate no reduction in major ischaemic events but an increased risk of major bleeding complications with routine DAPT when compared to SAPT. This guidance is yet to be incorporated into many local hospital protocols across England and leaves the potential for harm without offering benefit to patients.Purpose The aim of this study was to evaluate the use of antiplatelet medications for patients presenting with NSTEMI to secondary care, alongside the use of validated risk-stratification tools (using GRACE, HEART or TIMI scores) to guide treatment. The results were used to inform local ACS protocol development for a district general hospital (DGH) which does not offer a primary percutaneous coronary intervention (pPCI) service.Methods The data for 50 patients diagnosed as NSTEMI on admission at a DGH were retrospectively collected and analysed for adherence to risk-stratification recommendations and anti-platelet medication from admission until discharge. An ACS protocol was subsequently developed in conjunction with local cardiology, acute, and emergency care teams based on the updated 2023 ESC guidelines.Results Our study found a significant underuse of any validated risk-stratification tools by the admitting clinicians to guide clinical decision making ( figure 1). Furthermore, no evidence of a standardised approach for the management of these patients was identified when considering antiplatelet medication. A new protocol was developed to assist clinicians in treating patients presenting with ACS (figure 2).Abstract 24 Figure 1Abstract 24 Figure 2Conclusions Routine pre-treatment with DAPT in NSTEMI is associated with increased bleeding risk without improvement in major ischaemic outcomes when compared to SAPT with early invasive coronary angiography. In patients subsequently found to have alternative or non-coronary causes of troponin elevation, exposure to DAPT confers avoidable bleeding risk without clinical benefit. Local ACS protocols should incorporate SAPT-based strategies, supported by validated risk stratification to guide management.