Emergency department (ED) presentation with chest pain accounts for approximately 20% of acute hospital admissions, and delays in the investigation and management of these patients increase the pressure on emergency and medical departments. We implemented a pathway within our trust to improve the effi ciency of acute chest pain management. This included the development of a chest pain management algorithm, a short-stay heart assessment centre and a policy to immediately transfer acute coronary syndrome patients to cardiology. The introduction of the chest pain pathway resulted in fewer admissions from the ED with chest pain (34.2% vs 19.0%; p< <0.0001), a reduction in time from ED attendance to cardiology transfer (9.3 hours vs 5.7 hours; p< <0.0001) and a reduction in time to angiography (62.5 hours vs 26.6 hours; p< <0.0001). Length of stay was reduced for cardiology patients (4.7 days vs 2.4 days, p< <0.001) and mean length of stay for all patients attending ED with chest pain was reduced by 8.3 hours (27.5 hours vs 19.1 hours; p< <0.0001). The changes have signifi cantly improved the management of acute chest pain within our trust and we would suggest that adoption of these changes in other trusts could signifi cantly improve the quality of the care for these patients throughout the NHS.