Recent diagnostic and therapeutic advances have been questioning the role of exercise electrocardiography (ECG) for risk stratification of patients recovering from an acute coronary syndrome. The aim of this review was to verify whether evidence still exists supporting the use of exercise ECG as first choice stress testing modality in this clinical setting in the light of the most recent prognostic data and of cost effectiveness considerations. It was concluded that a large body of evidence supports the use of exercise ECG as a cost-effective tool for prognostic purposes and for quality of life assessment following acute coronary syndromes.