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The management of acute coronary syndromes remains largely grounded in the ST-elevation myocardial infarction (STEMI)/non-STEMI (NSTEMI) classification, a binary framework that assigns a central role to ST-segment elevation in guiding urgent revascularization. However, a substantial proportion of patients classified as NSTEMI may harbor an acute coronary occlusion, with consequent risk of delayed recognition and adverse clinical outcomes. This review focuses on how the suspicion of acute occlusive myocardial infarction (OMI) can be confirmed in the absence of traditional STEMI criteria. Emphasis is placed on the identification of subtle and dynamic ECG findings, including hyperacute T waves, reciprocal changes, posterior involvement, and evolving repolarization abnormalities, which may indicate ongoing coronary occlusion despite the lack of diagnostic ST-segment elevation. The emerging OMI/non-OMI paradigm challenges the traditional STEMI-centered approach by promoting a physiology-based interpretation of the ECG, integrating clinical presentation and serial biomarker assessment. In this context, the adoption of advanced tools, including artificial intelligence-powered ECG analysis, may enhance early recognition of occlusion patterns and support more timely decision-making. Improving the ability to identify OMI without STEMI criteria represents a critical step toward reducing treatment delays and optimizing clinical outcomes in patients with acute coronary syndromes.