Objectives: To study the relation between troponin positive acute coronary syndrome (ACS) and electrocardiogram (ECG) changes on admission. Materials and Methods: It was a prospective cohort study looking at patients admitted to the Heart Assessment Center over a period of a month, who were suspected to have an ACS. There were 126 patients in the cohort. The groups were classified depending on the number of cardiovascular risk factors: 0, 1, 2, 3, 4 and >4. The history and ECG changes during presentation were analyzed and the cardiac enzymes (12-hour troponin) were done. The final diagnosis was based on the expert opinion of the Consultant Cardiologist in combination with troponin positive results, and they were only further studied. Results: Of the 126 patients that were analyzed 31(25%) were diagnosed as ACS of which 26(21%) were troponin positive ACS. Among them, 13(50%) had ECG changes during admission, and 13(50%) did not have any noticeable ECG changes. Conclusion: Certain elements of the chest pain history and ECG changes are associated with increased or decreased likelihood of a diagnosis of ACS, none of them alone or in combination identify a group of patients that can be safely discharged without further diagnostic testing.