A 59-year-old-male patient with no previous medical history presented with oppressive chest pain; initial electrocardiogram showed ST segment elevation in aVR and V1, with intermittent right bundle branch block. Emergent coronary angiogram showed a proximal sub-occlusive stenosis of the left anterior descending artery, and the patient was hemodynamically unstable during the first 72 hours. Insights into the significance of ST segment elevation in aVR are presented and discussed in light of the current medical data.