Chest pain is a common presentation to the emergency department, accounting for approximately 700,000 presentations a year in England and Wales1,2 and accounts for approximately 8 million annual ED visits in the USA.3 The causes are myriad and it is important to excluded serious causes like acute coronary syndrome (ACS).4 This presents a daily dilemma for emergency physicians, which has led to the development of tools to assess risk. Six-month mortality prediction tools are recommended in the recently updated NICE Guidance for use in the ED for determining management of acute coronary syndrome.5 Although the GRACE score is mentioned as an example, the NICE guidance does not stipulate which score is recommended.5

How we get the diagnosis right in a safe and efficient way is in the top ten research priorities chosen by the James Lind Alliance Priority Setting Partnership run in conjunction with the Royal College of Emergency Medicine.6 TERNs ACS:ED study will investigate how chest pain of suspected cardiac origin is investigated in the Emergency Department.

There are implications behind excessive testing. Excessive cardiac investigation is associated with a longer length of stay, higher radiation exposures and higher health care cost, without demonstrating improved clinical outcomes for the patient.7