Chest pain is a very common condition. Patients may have a benign condition or present with a potentially lethal condition such as acute myocardial infarction, aortic dissection or tension pneumothorax. It is important to remember that patients may present with more than one serious pathology and that other serious conditions may potentially precipitate an acute coronary syndrome in a susceptible individual. We report the case of an elderly man with a background of chronic obstructive pulmonary disease who presented with sudden onset of chest pain and severe dyspnoea. Pneumothorax was diagnosed promptly and a chest drain inserted. His electrocardiogram (ECG) was abnormal and it is known that ECG changes do occur with spontaneous pneumothorax that have on occasions led to the incorrect diagnosis of acute myocardial infarction. Our patient had ongoing chest pain and it became evident that he also had developed an acute myocardial infarction.