Emergency physicians face significant liability in the diagnosis and management of patients with acute coronary syndromes. Newer diagnostic and therapeutic modalities continue to add to the tools that assist in sorting through the complexities of this group of patients. Nonetheless, the legal pitfalls continue unabated. Prudent patient care dictates vigilance in recognizing the atypical presentations, streamlining policies and procedures in the ED that impact on the management of these patients, and remembering that managed care policies affect payment, and not patient care.