Abstract Background: Many patients present to emergency departments with chest pain, but little is known about this population and the safest, most efficient testing strategies. We assessed clinical risk stratification of all patients with chest pain and, on a subset, utility of high-sensitivity troponin at 4 and 6 h after pain onset in aiding disposition decisions. Methods: Patients with intermediate or high-risk chest pain presenting within 6 h of onset were eligible for detailed study of troponin testing and outcome. Confusion, inability to speak English or need for urgent angiography was exclusion. Troponin levels were performed on arrival and at 4, 6 and 10–24 h from chest pain onset. Follow up of 30 days assessed compliance with, and results of, further investigation. Results: Chest pain accounted for 627 presentations over 112 days. Of 282 intermediate or high-risk presentations 144 (51%) presented more than 6 h after onset. The detailed study enrolled 52 patients with a troponin rise observed in 26%. In no cases did troponin increase between 6 and 10 h and, in five cases, fell. Follow up was achieved in 96%. Eight high-risk patients (40%) and four intermediate risk patients (13%) had positive stress tests. For discharged patients with outpatient investigations booked in emergency department 92% attended, while those with letters recommending investigations did not obtain testing. Conclusion: These preliminary data suggest that high-sensitivity troponin 6 h after chest pain onset may be diagnostically useful. Marked differences in outpatient testing attendance suggest bookings should be made before discharge.