Severe Hypocalcemia Masquerading as Acute Coronary Syndrome

Is the spiked helmet sign the manifestation of long QT syndrome?

We present the case of a patient with Takotsubo syndrome developing simultaneous inferior, anterior spiked helmet sign (SHS) and macroscopic T-wave alternans (TWA) leading to torsade de pointes ventricular tachycardia (TdP VT). Based on our observations we propose that the SHS is a type of manifestation of critically prolonged QT(U).

Spiked helmet pattern ST elevation in subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is occasionally associated with the electrocardiographic (ECG) pattern of ST-segment elevation myocardial infarction (STEMI). Missing the true clinical diagnosis can result in inappropriate and harmful interventions. We report the case of a 40-year-old female who was found down. The ECG was diagnostic for acute lateral STEMI. Further analysis of the ECG showed marked prolongation of the QT interval and the "spiked helmet sign" (SHS). The patient was ruled out for myocardial infarction and a head CT demonstrated a massive SAH with acute hemorrhage into the ventricles. Review of the literature and of our own ECG files revealed additional cases where severe acute central nervous system (CNS) conditions were associated with the SHS.

ST elevation due to hypercalcemia

Characteristic ECG changes with hypercalcemia include shortening of the QoT, QaT, and QeT intervals which are measured from the beginning of the QRS complex to the origin (O), apex (A), and end (E) of the T wave respectively. At very high serum calcium levels ECG changes include slight prolongation of the PR and QRS intervals, T wave flattening or inversion, and the appearance of a J wave at the end of the QRS complex. We present a case of a 22year-old male, who had been bedbound for 5months following a severe motor vehicle collision, presenting with shortening of the QoT and QaT intervals leading to anterior ST elevation mimicking acute myocardial infarction. Cardiac troponin testing was negative, however, laboratory testing revealed a serum calcium level of 15mg/dL (normal 7.3-10.5mg/dL). We review the published literature regarding the link between hypercalcemia and the appearance of ST elevation.