Distinguishing insignificant from life-threatening causes of acute chest pain in patients who present to the emergency department remains a major challenge. Initial evaluation with history, electrocardiography, and biochemical markers is often unrevealing leading to additional workup. Radionuclide perfusion and echocardiography may be diagnostic but provide only indirect assessment of coronary status. The development of multidetector computed tomography (MDCT) and its increasingly frequent placement near the emergency suite has facilitated its use for the evaluation of serious noncardiac diagnoses such as pulmonary embolism and aortic dissection. Recent innovations in MDCT technology have facilitated the depiction of coronary arteries. These advances have led to the possibility of using CT to evaluate cardiac etiologies of chest pain, using either a comprehensive or triple rule out protocol to assess both cardiac and noncardiac causes or a dedicated coronary protocol. This article will review both options and describes our preliminary experience with the first of these protocols. The article also reviews the potential value of an acute chest pain CT protocol and the considerable challenges that remain prior to its implementation for routine clinical use.