Clinical assessment of patients with acute coronary syndromes is routinely employed for risk stratification and selection of treatment strategies. Both, patients risk and treatment options vary in unstable angina, non-Q-wave infarction and massive Q-wave infarction. Clinical symptoms and admission ECG are the key elements in the daily work-up of chest pain patients. However, absent or nonconclusive ECG changes, even in patients with confirmed acute myocardial infarction, and high variability of clinical symptoms, particularly in elderly patients, limit their diagnostic value and their precision for risk stratification of acute coronary syndromes. Additional diagnostic testing such as 24 hours Holter ECG depicting prolonged episodes of ST-segment depression, and radio-nuclide tomography using Tc-Sestamibi improves accuracy of risk assessment. However, in clinical practise these techniques are not readily available. Troponins, particularly cardiac specific troponin T, are paramount for risk stratification of acute coronary syndromes, either alone, or in combination with admission ECG or a predischarge exercise stress test. Stratifying individuals into high, intermediate, and low risk for death and subsequent cardiac events may aid to improve outcomes by tailored use of a more aggressive therapy in these subjects.