Background: Chest pain is a common cause of emergency department (ED) visits and presents a diagnostic challenge due to its wide range of etiologies. Traditional diagnostic methods, such as electrocardiography (ECG) and cardiac biomarkers, insufficient in early or atypical presentations. Point-of-care ultrasound (POCUS) and transthoracic echocardiography (TTE) emerged as adjuncts for rapid bedside assessment. Our study aims to evaluate the diagnostic accuracy and clinical utility of POCUS and TTE in acute myocardial ischemia in patients presenting with chest pain, dyspnea, or suspected acute coronary syndromes (ACS) in the ED. Methods: A systematic review was conducted according to PRISMA guidelines. Studies included if assessed adult ED patients using POCUS or TTE for chest pain or cardiopulmonary symptoms. Data extracted on study design, demographics, inclusion criteria, ultrasound protocol, operator type, target conditions, reference standards, and diagnostic outcomes. Seven studies involving 2,727 patients were included. Results: POCUS and TTE improved diagnostic accuracy, increased physicians’ confidence, and reduced time to diagnosis. Sensitivity ranged from 60% to 92%, and specificity from 26% to 99%. The SEARCH 8Es and A–F mnemonic protocols were effective in rapid ED settings. POCUS shows better performance than chest X-ray in identifying pulmonary edema, pleural effusion, and pericardial effusion. Conclusion: POCUS and TTE are good diagnostic tools in the ED setting for patients with suspected myocardial ischemia. These imaging modalities can enhance diagnostic precision and expedite appropriate management when integrated with clinical and laboratory assessments.