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This study evaluates the diagnostic accuracy of an Emergency Medicine (EM) clinician at identifying ischaemia on an ECG using 30-day major adverse cardiac events (MACE) as the primary outcome.This is a secondary analysis of a prospective, multi-centre, observational cohort at 14 centres: the Bedside Evaluation of Sensitive Troponin study. All fourteen Emergency Departments were based in the United Kingdom. Emergency physicians’ assessments of the ECG were collected using a standardised form. Clinicians were asked to judge whether the ECG demonstrated ischaemia, the presence of ST depression (STD) and if there was abnormal T wave inversion (ATWI). Patients provided written informed consent and underwent serial high sensitivity troponin testing. 30 day follow-up was performed by research nurses using a standardised form via telephone. The primary outcome was 30-day major adverse cardiac events, defined as acute myocardial infarction, any cause of death and coronary revascularisation.In total, 756 patients were included in the analysis. Clinicians’ ECG diagnosis of ischaemia for 30-day MACE: ECG ischaemia produces a sensitivity (Sn) of 19.54% (95% CI:11.81% to 29.43%), specificity (Sp) of 93.27% (95% CI:91.10% to 95.05%), positive predictive value (PPV) of 27.42% (95% CI:18.47% to 38.65%) and negative predictive value (NPV) of 89.91% (95%CI 88.92% to 90.83%). ECG ST depression produces Sn of 16.09% (9.09% to 25.52%), Sp of 89.69% (87.13% to 91.89%), PPV 16.87 (10.68% to 25.62%), and NPV 89.15% (88.19% to 90.04%). ECG ATWI produces Sn of 4.60% (1.27% to 11.36%), Sp of 91.63% (89.27% to 93.62%), PPV of 6.67% (2.59% to 16.12%) and NPV of 88.07% (87.52% to 88.6).This is the first prospective, multi-centre cohort study, that assess the diagnostic performance of EM clinician’s ECG interpretation, with 30-day MACE as the primary outcome. The findings are highly relevant to EM as they represent the ECG terms used by popular acute coronary syndrome clinical decision rules. In this study a clinician’s overall judgement of ischaemia has a better diagnostic performance compared to simple STD and ATWI. This may be due to an appreciation of morphology and the amount of deviation; future work should explore the effect of measuring deviation and analysing morphology.