Introduction: Chest pain is the most common presentation of acute coronary syndrome presenting to Emergency department. Few patients may present with atypical symptoms and pose a great challenge to the Emergency physicians. Diagnosis has to be made early since maximal mortality occurs within first few hours if treatment is not instituted early. A cross sectional study was conducted in our hospital to study the proportion of atypical symptoms in patients with acute coronary syndrome. Methods: A cross sectional study was conducted in our hospital from August 2016 to September 2017. All patients aged >20 years presenting to Emergency department and fulfilling the following diagnostic criteria were included. The WHO diagnostic criteria were used for diagnosis of Acute coronary Syndrome(9). 1) Clinical history of Ischemic type of chest pain 2) Changes in serial ECG tracings a)ST–segment elevation of more than 1mm in 2 limb leads. b) ST–segment elevation of more than 2 mm in 2 or more contiguous chest leads. c) ST segment depression >0.5mm at J point in >2contiguous leads with positive troponin I. 3) Positive serum cardiac biomarkers (troponin I). The diagnosis was confirmed if 2 out of 3 above components were positive. ECG was done for all patients presenting to ER with symptoms suggestive of acute coronary syndrome. Cardiac enzymes were sent in patients with nonspecific ECG changes. Results: 323 patients were included in our study. Out of which, 269 patients presented with typical chest pain symptoms and 54 (16.71%) patients presented with atypical chest pain symptoms . The incidence in male and female population was 44.4% and 55.5% respectively. The incidence of atypical symptoms increased with increasing age and was highest in the age group of 71–80 years. Conclusion: It is crucial to consider acute coronary syndrome as a differential diagnosis in patients with atypical presentation and Emergency physicians should have a knowledge of various atypical presentations. As missed Myocardial infarction has dire consequences, continued efforts are required to reduce incidence, overall mortality and morbidity.