Recent advances in biomarkers have improved the evaluation of patients with acute chest pain, but current critical care pathways may still lead to important delays in early diagnosis and, hence, treatment of acute myocardial infarction (AMI). Electrocardiographic changes may occur within seconds of an ischemic insult, but the conventional 12-lead electrocardiogram (ECG) typically has only 50% to 60% sensitivity for diagnosis of AMI. Recording of multiple ECGs over a larger thoracic surface area, including the right ventricular, high left lateral, and posterior regions, by body surface mapping (BSM) has been made feasible in the setting of acute coronary syndromes by novel developments in electrode technology and simultaneous multichannel ECG data acquisition. Clinical studies of an Food and Drug Adminstration-approved BSM system (PRIME-ECG) have demonstrated improved early diagnosis of AMI in patients without 12-lead ST elevation and improved detection of right ventricular or posterior involvement in ST elevation MI. The improved diagnostic sensitivity compared with the conventional 12-lead ECG coupled with the potential reduction of delay to diagnosis compared with biomarkers suggest that BSM may have an important role as part of a chest pain critical care pathway for evaluation of patients with ischemic type chest pain.