Background and Aim: With respect to the increasing number of patients with cardiac pain and acute coronary syndrome and its progressive process and importance of prognostic predictors of ECG, this study was performed to determine the role of admission ECG on the prognosis of acute coronary syndrome. Material and Methods: In this case series study, during a 2-year period a total of 210 patients with acute chest pain and ECG changes attended during the first 12 hours to the emergency department were included. Associated ECG changes were T inversion, ST elevation, ST depression and ST elevation and depression. All patients were followed for 1 month after primary visit for absence of event and reinfarction and death. Role of ECG changes with death were evaluated with chi square and Fisher's exact test. Results: The study population included 127 males and 83 females with a mean age of 61±10.9 years. ECG changes were as follow T inversion 50.4%, ST elevation 12.4%, ST depression 29.1% and ST elevation and depression 8.1%. Only one patient in T-inverted group showed reinfarction in follow up. Death occurred in 2 patients of ST-elevated, 10 patients of ST- depressed and 5 patients of ST-elevated and -depressed group, respectively. Conclusion: Admission ECG in patients with acute coronary syndrome may predict the risk of early or late death, therefore, appropriate diagnostic and therapeutic interventions should be achieved earlier.