Isolated right ventricular ischemia in combination with myocardial infarction (MI) is uncommon, accounting for fewer than 3% of all MI cases. A young man who presented with acute right ventricular ischemia from occlusion of a codominant right coronary artery proximal to an acute marginal branch is presented. His presenting electrocardiogram (ECG) showed ST segment elevation in V1 to V4 mimicking acute anterior MI. ECG criteria for isolated right ventricular ischemia are discussed.