Chest pain and other symptoms suggestive of ACS make up the majority of presentations to hospital. 11 to 17 per cent of patients presenting to ED with such symptoms end up having the diagnosis confirmed. But follow-up studies of discharged patients show that up to six per cent of diagnoses are missed, and inappropriately discharged patients have a twofold higher mortality rate than those who are admitted.The 2016 guidelines of the Cardiac Society of Australia and New Zealand were developed to guide the rapid differentiation of patients presenting with suspected ACS. ACS takes in STEMI and non-STEMI heart attacks, and also unstable angina. This episode outlines the investigations used to distinguish these and other differential diagnoses associated with chest pain. First, electrocardiogram recordings are used to identify the occurrence of a myocardial infarction with ST segment elevation. If STEMI is discounted, the next most important step is to rule out other life-threatening causes of chest pain. Third in the diagnostic hierarchy is to establish whether there has been myocardial infarction without ST elevation, or unstable angina. This is where high sensitivity troponin markers become useful, and can feed into stratification protocols for assessing the risk of patients suffering future acute cardiac events.Guest Associate Professor Louise Cullen FACEM (Royal Brisbane and Women's Hospital, University of QueenslandProduction Written and produced by Mic Cavazzini. Additional audio recording from Michelle Ransom-Hughes. Music courtesy of Jason Shaw ('Minstrel, Pioneers'), Lee Rosevere ('Become Death'), Sergey Cheremisinov ('Pulsar') and Loch Lomond ('Listen, Lisbon'). Image courtesy of Science Photo Libary. The production manager was Anne Fredrickson.Editorial feedback for this episode was provided by RACP members Paul Jauncey, Pavan Chandrala, Rebecca Grainger, Phillip Gaughwin, Rhiannon Mellor, Alan Ngo, and Mahesh Dhakal. Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.

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