Barriers to the Implementation of Acute Coronary Syndrome Guidelines in Healthcare: A Systematic Review

Background: Clinical guidelines, pathways, and protocols assist in coordinating care for individuals with suspected or confirmed acute coronary syndrome (ACS). The recently updated 2025 ACS guidelines in Australia and internationally introduced significant changes to improve outcomes compared with the 2016 versions. However, barriers to implementing these ACS clinical guidelines in healthcare settings can lead to significant delays in the management of ACS patients, poor patient outcomes, and increased healthcare costs. This systematic review aims to identify the barriers that healthcare professionals face in implementing ACS clinical guidelines in primary and tertiary healthcare settings. Methods: Articles were identified through six databases encompassing EBSCO/Cumulative Index to Nursing and Allied Health literature, Cochrane's library, ProQuest, PubMed/Medline, ScienceDirect, and Web of Science, as well as hand searching. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework. Search terms included "barriers" OR "obstacles" and "Acute Coronary Syndrome" and "guidelines". A total of 1625 scientific papers discussing barriers to implementing ACS care guidelines were identified. Following the EndNote automated duplicate process, 67 duplicates were removed. A total of 1558 titles and abstracts were screened using the Joanna Briggs Institute System for Unified Management, Assessment and Review of Information (JBI Sumari). Of the records screened, 1482 were excluded; 76 full papers were retrieved and reviewed. Of these, 68 full-text articles were excluded; 8 studies were included in the final analysis. Results: The eight included studies were conducted in high-income countries (the USA, Australia, Norway) and low- and middle-income countries (Kenya, Egypt, Indonesia, Sub-Saharan Africa, Tanzania). Sample sizes ranged from 9 to 156,328 participants. Barriers to implementation were grouped into patient-, provider/staff-, and system-level factors. Patient factors included age, gender, race, lack of ACS knowledge, inappropriate healthcare-seeking behavior, delays in treatment, nonadherence to ACS management and lifestyle recommendations, nonattendance at diagnostic tests, language barriers, and geographical distance to the nearest healthcare setting. Provider/staff barriers included deficits in staff knowledge of patient triage, lack of confidence in managing patients with ACS, and deficits in diagnosis and in the provision of recommended management. System factors included inadequate training, the availability of guidelines/protocols, the condition/lack of equipment, and the absence of interventional cardiology units. In addition, factors included reduced available beds, high staff-to-patient ratios, shortages of qualified staff, delays in referral systems, delays in transport and treatment, and openness to adopting new guidelines. Conclusion: Accurate triage and risk stratification are essential to reduce ACS-related mortality. Health systems should prioritize timely electrocardiogram (ECG) interpretation, transport to percutaneous coronary intervention (PCI)-capable centers, and workforce training. Policy actions must address resource gaps, standardize chest pain pathways, and invest in infrastructure to ensure equitable implementation of the updated 2025 ACS guidelines. The PROSPERO Registration: CRD42023409325, https://www.crd.york.ac.uk/PROSPERO/view/CRD42023409325.