All patients attending an ED with chest pain that could be cardiac should be given a high triage priority to allow rapid assessment and treatment. All patients should receive adequate analgesia and aspirin. Patients with AMI who require fibrinolytic agents should be identified and treatment started. Other high risk patients need inpatient care and may need low molecular weight heparin. Low risk patients require rapid, cost effective and efficacious ROMI protocols, so they can be discharged safely. CPAUs provide the best way of achieving this. Currently the best early protocol seems to be serial CK-MB measurements and continuous ST segment monitoring.