Although typical chest pain is an important clinical feature required for diagnosis of acute coronary syndrome (ACS), many patients present with atypical complaints. The full extent and implication of this presentation is largely unknown. The study aim was to evaluate possible relations and temporal trends between presenting symptoms and outcomes in patients with ACS. Data was obtained from the Acute Coronary Syndrome Israeli Survey on patients presenting with typical chest pain versus atypical complaints, including dyspnea, nonspecific chest pain, palpitations or other. Temporal trends analysis examined the early (2000 to 2006) versus the late (2008 to 2016) period. During 2000 to 2016, 14,722 patients with ACS were enrolled; 11,508 (79%) presented with typical chest pain and 3,214 (21%) with atypical complaints. Patients with atypical complaints were older, majority female, and had more co-morbidities (p <0.001 for each). The 30-day major adverse cardiac events, 30-day mortality, and 1-year mortality rate were significantly higher in patients presenting with atypical complaints, (18% vs 13.5%, 7.7% vs 3.6%, and 15.6% vs 7.5%, respectively, p <0.001 for each). Although 1-year mortality decreased significantly over the years in patients with typical chest pain, there were no significant changes in patients who presented with atypical complaints. These results were consistent in STEMI and non-STE-ACS patients. In conclusion, ACS patients who present with atypical complaints have a less favorable outcome compared with patients who present with typical chest pain, and failed to show an improvement in mortality over the past 2 decades. Identification and utilization of guideline-recommended therapies in these high-risk patients may improve their future outcome.