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This is my talk for EUSEM 2020, in the Acute Coronary Syndromes session. We have seen some terrific advances in diagnostic technology in recent years. Decision aids and high-sensitivity cardiac troponin assays allow us to rapidly 'rule out' and 'rule in' the diagnosis of acute coronary syndrome (ACS) for many patients. But what about those who remain in the 'observation zone' or 'grey zone'? How do we ultimately decide whether they have an acute coronary syndrome, and how best to manage their care? In this talk I cover some key evidence to addres those questions, I illustrate this with three cases and I conclude that there are two key questions that we must answer for each patient we see in order to make these decisions.