This ECG shows ST-segment elevations in leads aVR, V1, V2, and aVL (where the ST-segment elevation appears to be of a lesser degree given the low voltage of the QRS complexes in that lead). There are scooped ST depressions in leads II, III, aVF, and V4-V6. PR-segment depression and a prolonged QT interval are also present. The ST-segment elevation in lead V1 is shown in greater detail (Figure 2). The differential diagnosis for these findings includes myocardial ischemia or infarction, or a severe metabolic derangement. This ECG, however, should be considered ischemic in the absence of severe electrolyte abnormalities. A similar pattern of ST-segment elevation in leads V1 and aVR, with the degree of ST-segment elevation greater in aVR than V1, was recently presented in the Archives.1 In the former case, the patient presented with crescendo angina and was found to have a 90% distal left main coronary artery stenosis.