Electrocardiographic left ventricular hypertrophy (LVH) and related repolarization changes alter the morphology of the ST segment and/or the T wave. Such electrocardiographic abnormalities--all features that are encountered in patients with acute ischemic heart disease--may confound the early emergency department evaluation of the chest pain patient. In the instance of the chest pain patient demonstrating ST segment/T wave abnormality, the correct electrocardiographic diagnosis must be made not only to offer appropriate management for that particular illness but also to avoid the incorrect application of potentially dangerous therapies such as thrombolysis. This report presents two cases in which the electrocardiogram demonstrated significant repolarization changes consistent with LVH, and focuses on the recognition of the expected ST segment/T waves changes and their differentiation from the primary ST segment/T wave changes associated with acute ischemic heart disease.