Modern care for acute ST-Elevation Myocardial Infarction (STEMI) involves rapid mobilization of cardiology resources including patient evaluation and transfer to a capable cardiac catheterization laboratory for coronary angiography and, when appropriate, for coronary intervention with stenting of the occluded infarct artery. However, not all patients presenting with chest pain and ST-Elevation on the ECG will have an acutely occluded coronary artery related to plaque rupture and thrombosis of atherosclerotic plaque. ST-elevation can result from other diagnoses such as pericarditis or early normal repolarization. ST-elevation can be a chronic finding in patients with prior MI. In addition, coronary arteries can become acutely occluded by other mechanisms such as embolism of vegetation (endocarditis), severe coronary spasm, or spontaneous coronary artery dissection (SCAD). In this case, we present a patient with STEMI and there is a diagnostic and therapeutic challenge.