What to do now

1. Do not wait for an OPD follow-up. Arrange urgent hospital admission and inform the receiving unit:
   “Chest pain yesterday, severe hypertension 170/110, ECG with anterior QS complexes and persistent ST elevation, received aspirin 300 mg, atorvastatin 80 mg and sublingual nitrate.”
2. Repeat a proper 12-lead ECG immediately and compare it with this one. Do serial ECGs if there is any recurrent pain. Obtain right-sided/posterior leads if clinically indicated.
3. At hospital, obtain:
   • High-sensitivity troponin now and repeat as per local ACS pathway
   • Continuous ECG/rhythm monitoring, IV access, pulse oximetry
   • CBC, creatinine/eGFR, electrolytes including K/Mg, glucose/HbA1c, LFT, coagulation profile, lipid profile
   • Urgent transthoracic echocardiography: regional wall-motion abnormality, LVEF, LV thrombus, mechanical complication
   • Cardiology assessment for urgent coronary angiography and PCI/revascularization

Medicines while arranging transfer

• Aspirin: He has already received 300 mg loading. Continue 75-100 mg once daily, unless there is active bleeding, true aspirin allergy, etc.
• High-intensity statin: Continue atorvastatin 80 mg nightly.
• Second antiplatelet agent: He needs a cardiology-directed P2Y12 inhibitor loading dose as part of dual antiplatelet therapy, typically ticagrelor or clopidogrel depending on the planned strategy, bleeding risk, affordability, prior stroke/TIA, and likelihood of CABG. Do this in coordination with the receiving cardiologist/cath lab rather than treating it as routine outpatient medication.
• Anticoagulation: UFH/enoxaparin is generally part of confirmed ACS/STEMI care, but should be started in hospital or under the accepting cardiologist’s direction, using weight, creatinine and planned PCI/fibrinolysis strategy. Do not give a fixed outpatient dose without these details.
• Nitrates: Sublingual GTN can be used only for recurrent ischemic pain if SBP is adequate and there is no right-ventricular infarction, severe aortic stenosis, or recent sildenafil/vardenafil within 24 hours or tadalafil within 48 hours. Stop if BP falls, dizziness develops or pain persists. Nitrate response does not rule MI in or out.
• Oxygen: Only if hypoxemic, respiratory distress, or shock. Do not give routine oxygen if saturation is normal.
• Pain: Avoid NSAIDs such as diclofenac, ibuprofen, or nimesulide in suspected ACS. Use hospital analgesia if needed.
• BP 170/110: Do not abruptly lower BP in the clinic. Recheck manually and assess for pulmonary edema, neurological symptoms, aortic dissection features and ongoing ischemia. IV BP treatment, if required, should be monitored in hospital. Nitrates can lower BP but are not a substitute for definitive ACS care.

Drugs to consider only after admission and assessment

• Beta-blocker only if no acute LV failure, shock/low-output state, bradycardia, significant AV block, asthma/bronchospasm, or other contraindication.
• ACE inhibitor/ARB after stabilization, especially if hypertension, diabetes, anterior MI, reduced EF, or heart failure, after checking creatinine and potassium.
• MRA if LVEF is reduced with heart failure/diabetes and renal function/potassium permit.
• Post-MI antiplatelet therapy is usually aspirin plus a P2Y12 inhibitor for about 12 months if bleeding risk permits, with duration adjusted by the cardiologist. The ACC summary of the 2025 guideline recommends DAPT as the default after ACS in patients without high bleeding risk, along with high-intensity statin therapy.

Tell him to seek emergency help immediately if any of these occur

• NSTEMI usually has elevated troponin with no persistent diagnostic ST elevation.
• STEMI requires symptoms compatible with MI plus new or presumed-new ST elevation in contiguous leads. The current ECG threshold is ST elevation in at least 2 contiguous leads, with higher thresholds in V2-V3. See the 2025 ACC/AHA ACS guideline criteria.