ST segment elevation is seen in inferolateral leads (II, III, aVF, V5, V6) indicating inferolateral ST elevation myocardial infarction (STEMI). There is a discordance between the ST segment in aVL and V6 – there is ST segment depression in aVL while the ST segment is minimally elevated in V6. STEMI is an indication immediate angiography and percutaneous coronary intervention (PCI). If that is not feasible, either the patient can be transferred to a PCI capable center or thrombolytic therapy administered if there are no contraindications. Differential diagnosis of this pattern is of course an early repolarization (ERPS) pattern. But ST segment depression in aVL is unlikely to be seen with ERPS. Clinical history, estimation of cardiac troponins and echocardiography to look for wall motion abnormality will help in differentiating the two conditions.