This clinical vignette describes a 68-year-old female presenting with acute epigastric pain, nausea, and diaphoresis. Despite her atypical symptoms, her significant cardiovascular risk factors, including hypertension, diabetes, and hyperlipidemia, prompt early suspicion for acute coronary syndrome (ACS). Though her history of gallbladder disease initially expands the differential, an ECG reveals ST-elevations in II, III, and aVF consistent with an inferior STEMI. The case highlights the importance of recognizing atypical presentations of myocardial infarction in older adults, especially women and diabetics, and emphasizes the role of prompt ECG interpretation and cath lab activation. Learners will explore the nuances of STEMI criteria, the concept of occlusion myocardial infarction (OMI), and the clinical implications of inferior-wall involvement, including preload sensitivity. The case also reviews antiplatelet and anticoagulant management strategies, differentiates between OMI and mimics, and reinforces the need for early cardiac intervention in high-risk presentations.