We investigated the clinical features and management of 50 patients presenting with acute myocardial infarction from the community and 50 patients presenting with cardiac symptoms who developed an infarct after being admitted to a general medical ward for observation. Nineteen of the 50 patients initially admitted to non-specialist wards were found retrospectively to have sustained an infarct prior to hospital admission. Of the remaining 31 admission in this group, 24 developed symptoms within 24 hours of admission, 26 presented with chest pain, while 21 had evidence of acute coronary ischaemia on the admission electrocardiograph. Of the 26 patients who presented with chest pain, 20 were treated with aspirin, 13 with intravenous nitrate and four with heparin. Median delay from onset of symptoms to thrombolysis with in-hospital patients was 120 minutes and for community patients 287 minutes. Interestingly, the greatest component of this delay in both groups was the time taken for patients to decide to seek assistance after developing acute symptoms. Patients at high risk of developing acute myocardial infarction within 24 hours of hospital admission may be identified by a history of chest pain and electrocardiographic evidence of acute coronary ischaemia at admission. Such patients may experience suboptimal treatment and delays to thrombolysis if admitted to nonspecialist wards, but this may be reduced by admitting all 'high risk' patients directly to a high dependency cardiac ward for the first 24 hours after presentation.