Acute coronary syndrome and myocardial infarction have been described to present with atypical symptoms in certain subsets of patients. However, these subsets commonly do not include middle-aged males with a paucity of underlying medical conditions. We present a very unique case of acute coronary syndrome in a 53-year-old male, with no previously identified medical conditions other than chronic back pain. The patient was encountered by rural emergency medical service providers presenting with syncope followed by intermittent episodes of lightheadedness. Further, electrocardiographic changes consistent with acute ischemia could only be demonstrated with the patient in a standing position, prior to the development of an occurrence of ventricular tachycardia, which degenerated into ventricular fibrillation. To our knowledge, this is a very rare case of electrocardiographic changes consistent with occult, acute cardiac ischemia with a proven coronary artery lesion seen initially only with the patient in a standing position.