Acute coronary syndrome (ACS) most commonly presents with chest pain; however, in elderly patients with comorbidities such as hypertension, diabetes mellitus, and hyperlipidemia, ACS may present with atypical symptoms including dizziness, fatigue, and headache. These presentations may result in delayed diagnosis and increased mortality.A 67-year-old male presented to a family medicine clinic for prescription refills. His medical history included hypertension, diabetes mellitus, hyperlipidemia, benign prostatic hyperplasia, and generalized anxiety disorder. He reported irregular use of antihypertensive medications. The patient complained of mild dizziness, fatigue, and frontal headache lasting three days and denied chest pain, nausea, vomiting, weakness, or sensory disturbances. On examination, blood pressure was 189/96 mmHg and pulse rate was 62 beats per minute. Capillary blood glucose was 190 mg/dL, and glycated hemoglobin (HbA1c) was 7.0%. Electrocardiography showed normal sinus rhythm, and neurological examination was unremarkable. The patient was referred to the emergency department.NSTEMI was identified in primary care despite absence of chest pain.Atypical ACS presentations are common in elderly patients and individuals with diabetes mellitus. Absence of chest pain may lead to underestimation of cardiac risk in primary care. Early recognition of atypical symptoms and timely referral are essential to prevent adverse outcomes.NSTEMI may present solely with mild dizziness and uncontrolled hypertension. Family physicians should maintain a high index of suspicion for ACS in high-risk patients.Family physicians should recognize atypical NSTEMI presentations.