The problem of pre-hospital management of acute coronary syndromes without ST elevation has not been extensively studied. The practitioner is faced with three simultaneous problems: suspecting the diagnosis, how to confirm the diagnosis to introduce appropriate, rapid and effective treatment, and which prognostic criteria to use to install aggressive therapy in high risk groups (anti GP lIb/IIIa, clopidogrel, angioplasty). TOSCANE is the first multicentre French registry which analyses the impact of the emergency ambulance serve in the management of these patients. There are two objectives: to gather epidemiological data about pre-hospital and hospital management by the emergency physician and the cardiologist, and to identify at an early stage criteria of "high risk" (HR) which, according to the recommendations of the European Society of Cardiology, justify using the most aggressive therapies. From April to September 2003, 797 patients with suspected acute coronary syndromes were enrolled by 36 French centre. Of these patients, 780 were managed successfully by the emergency ambulance service and hospital cardiological department with or without a "Cath Lab", and included for analysis. The diagnosis of acute coronary syndrome without ST elevation was rarely certain in the pre-hospital period. The lack of formal paraclinical features confirming the diagnosis was often a handicap for the emergency physician. Although the European recommendations are well observed in the cardiology departments, their application and adaptability should be improved in the pre-hospital period. TOSCANE showed that all invasive strategies preceded by platelet anti-aggregant therapy in the prehospital period administered to high risk patients, significantly reduced the mortality and morbidity at one month.