With persistent/prolonged chest pain and an abnormal ECG, my initial impression is that the patient should have been brought to the cath lab for urgent angiographic evaluation and possible PCI. Other things that are in your mind when evaluating someone with this presentation include pulmonary embolus, or aortic dissection, but the most common cause of this presentation is an unstable/acute coronary syndrome. Even a normal ECG does not exclude a myocardial infarction/acute coronary syndrome, as in certain coronary territories (e.g. the left circumflex) the ECG can be deceivingly normal. As such, clinical judgement based on the patient’s presentation and other clinical parameters (e.g. coronary risk factors etc.) is crucial. So, in this relatively young patient with 45 minutes of chest pain and an abnormal ECG, unless an alternative explanation for the chest pain was readily apparent, urgent evaluation in the cath lab would be indicated. The type of ECG abnormalities would also be important to consider. Any ECG abnormality that was suggestive of myocardial ischemia or MI, in a patient who presented with 45 minutes of chest pain, would be a strong indication to bring the patient to the cath lab urgently. Also, if a previous ECG was available, and this one was different, that would also strongly indicate the need for an urgent cath.