The electrocardiogram (EKG) is a useful diagnostic tool that allows clinicians to rapidly evaluate patients for acute coronary syndrome. With the high prevalence of heart disease in society, the EKG is crucial in the evaluation of chest pain and diagnosis of ischemia. Various guidelines provide criteria to aid in recognizing ischemia and help dictate patient management. Not all ischemic patterns requiring emergent management present within the classic definition of an STEMI. It is critical for clinicians to be able to accurately recognize these ischemic patterns to allow timely and appropriate cardiovascular care.