Graphical Abstract Graphical Abstract Pros and cons of a healthcare cost-driven strategy. Chest pain is among the most common diagnoses for admission to the emergency department (ED). The current strategy for assessment and management of patients with chest pain with suspected acute coronary syndrome (ACS) is to be referred to the ED regardless of the estimated cardiovascular risk. This in turn may result in overcrowding of the ED and increased costs for the healthcare system. The ARTICA trial proposes a healthcare cost-driven strategy and shows that ambulance triage of patients with chest pain can identify patients at low risk of ACS that can be referred to the general practitioner. From a healthcare cost perspective, pre-hospital assessment of ACS risk can reduce the healthcare costs by reducing the number of ED referrals and promote an effective use of health resources. At present, several questions need to be addressed before pre-hospital triage can be implemented: safety and sustainability in different healthcare systems and validation of the troponin point of care measurements.