Acute Coronary Syndrome (ACS) is a common diagnosis in the emergency department (ED), the most severe manifestation of which is ST elevation on electrocardiogram (ECG). ST elevation reflects obstruction of flow through the coronary arteries, most commonly due to coronary atherosclerotic plaque rupture. However, alternative causes of coronary obstruction causing ST elevation are possible. Spontaneous coronary artery dissection (SCAD) is an unusual cause of ST elevation in ED patients which providers may encounter in patients without traditional atherosclerosis risk factors. Patients presenting with SCAD as a cause of ST elevation require unique management from traditional ACS. Here we report a case of a 43 year old female presenting with chest pain and unusual ECG findings including accelerated idioventricular rhythm followed by subtle ST segment elevation and resolution of abnormalities. This case illustrates subtle clinical and ECG findings suggestive of SCAD which emergency physicians should consider when evaluating patients for ACS in the absence of traditional clinical presentations. Such considerations may prompt physicians to avoid therapy for coronary plaque rupture which is not indicated in patients with SCAD.