[2010] 1.2.2.5 Do not exclude an ACS when people have a normal resting 12-lead ECG. 1.2.2.6 If a diagnosis of ACS is in doubt, consider: taking serial resting 12-lead ECGs reviewing previous resting 12-lead ECGs recording additional ECG leads. Use clinical judgement to decide how often this should be done. Note that the results may not be conclusive. [2010] 1.2.2.7 Obtain a review of resting 12-lead ECGs by a healthcare professional qualified to interpret them as well as taking into account automated 1.2.2.8 If clinical assessment (as described in recommendation 1.2.1.10) and a resting 12-lead ECG make a diagnosis of ACS less likely, consider other acute conditions. First consider those that are life-threatening such as pulmonary embolism, aortic dissection or pneumonia. Continue to monitor (see recommendation 1.2.3.4). [2010] 1.2.3 Immediate management of a suspected acute coronary syndrome Management of ACS should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances. 1.2.3.1 Offer pain relief as soon as possible. This may be achieved with GTN (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected. [2010] 1.2.3.2 Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow the NICE guideline on acute coronary syndromes. [2010] 1.2.3.3 Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. 