OBJECTIVE To determine the prevalence and nature of chest radiographic abnormalities in patients presenting to the emergency department (ED) with suspected acute coronary syndrome but without signs or symptoms of other pathology. METHODS A retrospective study was undertaken of patients presenting to a tertiary referral ED between July 2005 and June 2006. Inclusion criteria were age > or = 18 years and suspected acute coronary syndrome (as defined). Exclusion criteria were any signs or symptoms consistent with other cardio/pulmonary pathology (as defined). The study end points were the proportion of patients who had a chest radiograph, the proportion who had an abnormal chest radiograph, the nature of the abnormality and whether the radiograph changed management. RESULTS Of 158 patients who met the entrance criteria, 130 (82.2%, 95% CI 75.2% to 87.7%) underwent chest radiography. In 40 patients (30.8%, 95% CI 23.1% to 39.6%) an abnormality was reported by the radiologist, although most were of no consequence (eg, previous sternotomy). In three patients there was documented evidence that the chest radiograph altered management (one was treated for pulmonary oedema, one for pneumonia and one was investigated further for suspicious hilar nodes). In a further two patients (one with middle lobe collapse and consolidation and one with pulmonary oedema) the chest radiograph may have changed management, although this was not documented. CONCLUSIONS In the patient group examined, chest radiography resulted in a low yield of unexpected chest pathology. Routine chest radiography for this group is questionable and needs further investigation.