Chest pain or other symptoms concerning for acute coronary syndrome continues to remain a major reason for presentation to the emergency department. However, there is significant heterogeneity in the spectrum of risk severity of these patients. The electrocardiogram (ECG) remains a critically valuable tool in the physician’s arsenal to diagnose patients and help with risk stratification. There are multiple high-risk ECG findings that are suggestive of adverse outcome and may benefit from rapid transfer for coronary angiography. This article reviews specific high-risk ECG patterns that may represent acute myocardial infarction or identify impending acute myocardial infarction that benefit from early diagnostic coronary angiography.