The prevalence of coronary heart disease is massive within the UK and is the leading cause of myocardial infarction. Between a third and two thirds of associated deaths occur in the pre hospital setting, many within the first few minutes of symptom onset. Immediate quality treatment is proven to improve patient survival however recent evidence suggests patients are not receiving all the elements of a quality care bundle. Pain management has been identified as one area which requires national improvement to meet standards directed by the National Service Framework for Coronary Heart Disease. In response, Ambulance services nationally have used clinical performance indicators to address quality issues in order to enhance practice and achieve target. This article reviews the importance of pain relief in the treatment of acute coronary syndrome and analyses the use of clinical performance indicators in the pursuit of best practice within the North West.