Acute chest pain is one of the most common symptoms in emergency departments. Immediate assessment is mandatory on arrival in order to ensure the appropriate care. Diagnostic work-up should be based on conventional tools, i.e. clinical presentation, physical examination, electrocardiogram, as well as on modern information, i.e. biochemical markers of myocardial damage or provocative tests. Firstly, physicians should assess the likelihood that signs and symptoms have a cardiac origin secondary to coronary artery disease. Afterwards, the risk for ischemic complications should be stratified. To this end, several scores have been derived from clinical trials in order to improve prediction of outcome. Also, use of critical pathways can improve guideline adherence. In the "real world", a variety of barriers to optimal management of acute chest pain still exists. An agreement on specific protocols is often difficult to achieve between different specialties. Also, no official guidelines on low-risk chest pain patients or patients with non-cardiac chest pain are available. Finally, the minimal data set of diagnostic tools that should be applied in case of acute chest pain in any emergency setting is still lacking
