Chest pain characteristic 1 Substernal chest discomfort with a characteristic quality and duration 2 Provoked by exertion or emotional stress 3 Relieved by rest or nitroglycerine Meets 3/3 = typical angina, Meets 2/3 = atypical angina, Meets 0-1/3 = noncardiac chest pain Careful of atypical presentation especially in elderly, woman, diabetic patients Beware of subtle STEMI Oxygen supplementation only if Oxygen saturation < 90% For unstable bradycardia, try atropine then dopamine and stand by transcutaneous pace maker In hypotensive patient may try iv fluid first if no signs of pulmonary edema if adequate volume, start norepinephrine For Antiplatelet, in elderly > 75 year-old that will received fibrinolytic agent give ASA gr. v 1tab, plavix 1 tab, in other cases ASA gr v 1 tab plavix 4 tab 120 minutes is time that determine primary PCI or fibrinolytic agent 4 extremities blood pressure and cardiac ultrasound before Fibrinolytic agent to look for Aortic dissection Don’t forget pain control Don’t forget to treat heart failure Accelerated idioventricular rhythm(AIVR) is a good sign of reperfusion