ACS questioning.

[rescue1]

Anecdotally, I've never actually met anyone who actually caused a dangerous hypotension with nitroglycerin, though I've been warned about it my whole career. This study suggests that the risk of hypotension with RV involvement is basically the same as non-RV MI. https://www.ncbi.nlm.nih.gov/pubmed/26024432
That being said I don't think I'd risk it, given the lack of mortality benefit from nitro.

As for patients given nitro at home, remember that nitrates are mostly taken at home to treat angina, so it's very likely a patient could have taken them for what then turns out to be a right sided MI. I could be wrong but I don't believe there's any screening for right sided involvement before nitro is prescribed.

And as others have mentioned, while nitro does decrease cardiac work in angina, in ACS it is primarily an analgesic.

"Nitrate therapy has an important role in the management of patients with an acute coronary syndrome, despite the absence of a mortality benefit. It can be of value in reducing or potentially eliminating pain (either initial or recurrent) due to myocardial ischemia, improving symptoms of pulmonary congestion, lowering blood pressure in hypertensive patients, and aiding in the diagnosis and management of the rare patient who presents with variant angina (coronary artery spasm)."

 

[StCEMT]

Everyone else already answered their general ACS questioning pretty detailed, the only thing I will add is don't let yourself get tunnel vision based on the lack of chest pain. I brought in an MI last year with a history of COPD and some other pulmonary issues who was complaining of difficulty breathing, which was absolutely true. He looked like **** and was definitely working to breathe. I did a 12 lead just because he didn't look good and something didn't feel right, not because of any stereotypical cardiac complaint and sure enough he had a nice anterior STEMI. If something looks off with vitals, someone looks generally crappy, or that little voice in your head doesn't have warm fuzzy feelings, then do a 12 lead. A lot of MI's have been caught just by casting a wide net by people who didn't even have an MI at the top of their list.