Scenario: This prehospital 12-lead electrocardiogram (ECG) was obtained on a 70-year-old white man who called 9-1-1 for chest pain that started suddenly while at rest. The patient remained alert and oriented but had a low blood pressure of 80/50 mm Hg. The only significant feature in his medical history was hypertension, for which he had been taking a β-blocker. The initial cardiac troponin level was negative.

Normal sinus rhythm with global ST-T wave changes. No evidence of secondary (nonischemic) repolarization abnormalities that can alter the ST-T wave (ie, bundle branch block, ventricular pacing, ventricular rhythm, or left ventricular hypertrophy) is apparent. The observed ST-T wave changes in this patient appear to be ischemic in nature. Differential diagnoses include non-ST elevation acute coronary syndrome (NSTE-ACS); other uncommon diagnoses could include myocarditis, aortic dissection, cardiomyopathy, pulmonary embolism, and acute pancreatitis.

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