One of the current focuses of the chest pain emergency department (CPED) movement is to improve community awareness of chest pain signs and symptoms and thereby encourage patients to be evaluated early. However, such a strategy may overwhelm the mechanisms currently in place to evaluate these patients in a timely and cost-effective manner. In this article, the author reviews the experience of St. Agnes HealthCare using acute myocardial perfusion imaging (MPI) to help stratify patients who present with chest pain and nondiagnostic or normal ECG into low- and high-risk groups for the development of acute cardiac events. Currently, St. Agnes is participating in a randomized, multicenter trial to assess clinical and cost efficacy of employing a strategy of acute MPI in the CPED.