Spiked helmet sign and STEMI

Given the extremely rare occurrence of the association of the spiked helmet sign (SHS) and ST-elevation myocardial infarction (STEMI), and the variability of its underlying causes, even in that context,1–5 it would be difficult to substantiate the claim that the SHS is ‘an electrocardiographic hallmark of acute LAD occlusion’.1 Notwithstanding the fact that SHS is a well-documented manifestation of anterior STEMI,1–3 the entity of inferior myocardial infarction (attributable to right coronary artery (RCA) occlusion) also needs to be recognized as an underlying cause of the development of the SHS, as shown by the following examples: The ECG showed ST-segment elevation in the inferior leads, with concurrent stigmata of SHS. Serum troponin T was elevated to >2000 ng/dl. Chest X-ray showed pulmonary oedema. Coronary angiography showed 90% stenosis involving the proximal segment of the RCA and subtotal occlusion in the distal RCAs, with slow flow. The patient underwent successful percutaneous coronary intervention. However, the patient died the following day from severe heart failure.5