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The patient with a decreased level of consciousness in the absence of trauma presents difficult assessment and intervention problems. This is compounded when the history is vague or nonspecific. In this case, the patient's history of embolic CVA alerted providers to the possibility of another thrombus. This patient's sudden symptoms could have resulted from a clot in the brain, heart or aorta. This patient presented with an altered level of consciousness, vomiting and low blood pressure. As is typical in elderly female patients, she had an unusual presentation of an MI. A myocardial infaction is classified as either transmural or subendocardial. A transmural infarct extends through the full thickness of the myocardium and holds greater-risk of complications due to loss of functional muscle. In a subendocardial infarct, necrosis is limited to the endocardial surface. Although many elderly patients present with subendocardial MIs, this one had a large transmural MI. In general, the circumflex artery serves the lateral and posterior walls of the myocardium, and the right coronary artery (RCA) serves the inferior wall. In an anterior MI, the left anterior descending artery (LAD) is obstructed. This vessel serves the left ventricle, parts, of the septum and paillary muscles. The LAD is often referred to as the "widowmaker" because left ventricular infarcts have a high incidence of mortality. Occlusion of LAD can cause the usual damage of an MI, and can also cause fatal damage to the valves. This patient was in profound cardiogenic shock -- the left ventricle had infarcted and was unable to maintain cardiac output. Because of her recent stroke, she was not a candidate for thrombolytic medication. With ultrasonography, a large area of the anterior wall was found to be akinetic, or not functioning at all. In this care, the sourrounding myocardium not only has to pump blood with less muscle but also to "drag" the dead tissue. This results in a progressively higher rate of O2 cnsumption within the heart, further damage to the strained heart, and death. As cigarette smoking and obesity complete for the leading preventable cause of death in the United States, familiarity with cardiac anatomy and physiology 12-lead interpretation, pharmacology and electrical therapy is essential for all emergency providers