The evaluation of adolescents with chest pain, elevated cardiac enzymes, and abnormal electrocardiograms (ECGs) continues to pose diagnostic and management dilemmas. Myocardial infarction is an uncommon finding in this population and alternative diagnoses must be considered. Our database was retrospectively reviewed for adolescents age 16–18 years without prior cardiac history who underwent cardiac catherization. Patients who presented with chest pain, elevated cardiac enzymes, normal ejection fraction, and abnormal ECGs were included. Management, diagnostic testing, and final diagnosis were reviewed. Nine adolescents (eight males and one female) without prior cardiac history were identified. The ECG findings in all patients were consistent with myocardial ischemia in a coronary distribution. Thrombotic coronary occlusion was not found in any patient. In adolescents without prior cardiac history of risk factors for myocardial infarction such as Kawasaki disease, familial hypercholesterolemia, or drug use who present with chest pain, multiple diagnoses must be considered even in the presence of focal ischemic ECG changes and elevated cardiac enzymes. Thrombolytic therapy or anticoagulation should be withheld until a definitive diagnosis of myocardial infarction has been made. Magnetic resonance imaging is the most useful tool to differentiate focal myocarditis from myocardial infarction.