1. Differential Diagnosis

• Inferior Myocardial Infarction (MI): Given the ST-segment elevation in leads II, III, and aVF, this is highly suggestive of an inferior MI.
• Right Ventricular (RV) Infarction: Consider this due to hypotension and inferior MI. RV involvement leads to decreased preload and can cause significant hypotension.
• Pericarditis or Myocarditis: Less likely, but can present with chest pain and should be considered if acute coronary syndrome is ruled out.
• Aortic Dissection: Possible with severe chest pain and hypotension; however, the ST elevation is more indicative of MI.
• Pulmonary Embolism (PE): Chest pain and hypotension can be consistent; however, ST elevation in inferior leads makes this less likely.

2. Clinical Assessment

• Vital Signs: Hypotension (88/50 mmHg) and tachycardia (HR 110 bpm) are concerning and indicate potential shock, possibly indicative of RV involvement due to inferior MI.
• Oxygen Saturation: 92% indicates mild hypoxemia, warranting supplemental oxygen.
• Medical History: The patient has hypertension, hyperlipidemia, and a significant smoking history, all of which are risk factors for coronary artery disease.

3. Recommended Next Steps (Labs/Imaging)

• Rapid Response Team Activation: Immediate assessment may be necessary to manage hypotension.
• Cardiac Biomarkers: Troponin I or T levels to confirm myocardial injury.
• Consider Bedside Echo: To assess for RV function and determine presence of mechanical complications.
• Electrolylytes and Acute Kidney Injury Panel: To rule out any metabolic causes of hypotension.

4. Treatment Recommendations

• Heparin: Initiate Heparin immediately given high suspicion of acute coronary syndrome, especially if RV involvement is suspected. This should not wait for cardiology consult.
• Fluids: Administer IV fluids cautiously to manage hypotension, especially in the setting of potential RV infarction.
• Oxygen Therapy: Provide supplemental oxygen to improve saturation levels.
• Cath Lab Activation: As noted, this should be prioritized alongside Heparin administration.
• Cardiac Monitoring: Continuous telemetry to monitor for arrhythmias and hemodynamic stability.

Please ensure prompt engagement with the cardiology team throughout this process for continued management.