An 84-year-old man was brought to our emergency department by ambulance with intermittent pain in the upper abdomen and shortness of breath for three hours. He had a history of coronary three-vessel disease (first diagnosis 2004) with prediabetes, hypertension, hyperlipidemia, and past history of active smoking. Vital signs were in the normal range. Rapid first clinical assessment was unremarkable. The first ECG was seen on the monitor in lead II (). The ECG “strip” showed sinus rhythm at 76 beats per minute with apparent ST-segment elevation, but with the upward shift starting before the onset of the QRS complex. This pattern was consistent with the “spiked helmet” sign. Lung auscultation showed bilateral vesicular breath sounds. Abdomen was soft and nontender with reduced peristalsis. Focused point-of-care ultrasound was performed with ubiquitous pleural sliding excluding a large pneumothorax and abdominal examination ruling out free fluid and gastrointestinal distension. We obtained in parallel a 12-lead ECG (). The ECG showed a sinus rhythm at 78 beats per minute with first-degree atrioventricular block, right bundle branch block and ST-elevation in the inferior leads, again with the upward shift starting before the onset of the QRS complex. Due to the reciprocal ST-depression in lead I and aVL, the catherization lab was activated and the patient underwent coronary angiography. The cardiologist found an occlusion of the distal right coronary artery (RCA), which was the dominant vessel. The occlusion of the RCA was balloon-dilated followed by angioplasty. A post-interventional ECG with asymptomatic patient was obtained (). The “spiked helmet” sign had resolved, with all that remained a nonspecific intraventricular block in the inferior leads and a slightly long corrected QT interval (QTc) of 480 milliseconds. The first 24 hours after intervention was uneventful. However, on the second day the patient had a fulminant collapse with hemodynamic instability. The patient had declared earlier to abstain from further intensive care therapy. Supportive therapy was performed and he died a few hours later.