Cocaine remains the most common cause of illicit drug-related visits to emergency departments, 40% of which result from chest pain. It is estimated that over half of the 64,000 patients evaluated annually for cocaine-associated chest pain will be admitted to hospitals for the evaluation of myocardial ischemia or infarction, at a health care cost of over eighty million dollars. Although the link between cocaine use and myocardial ischemia is well established, only about 6% of patients with cocaine-associated chest pain will demonstrate biochemical evidence of myocardial infarction. This article focuses on the evaluation of patients with chest pain following cocaine use, and concentrates on ways to improve diagnosis, management, and utilization of health care services.