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ST segment elevation is an important electrocardiographic (ECG) change that is typically found in acute myocardial infarction, but may also be seen in a variety of other conditions. MRI plays an important role in the evaluation of these patients. MRI not only establishes the diagnosis, which is essential for appropriate management, but also helps in the assessment of other factors that are important for risk stratification. In this review, we discuss the common and uncommon causes of ST segment elevation and the role of MRI in the evaluation of these disease processes.