The heart tracing was alarming enough to send a 42-year-old man straight to emergency heart catheterization. His ECG showed severe ST-segment elevation across multiple leads, the pattern doctors are trained to treat as a heart attack in progress.
His coronary arteries turned out to be normal. Six hours later, his ECG had returned to normal as well.
The explanation, described in a case report published May 20 in JACC: Case Reports by Dr. Mazen M. Kawji of OSF HealthCare's Cardiovascular Institute in Peoria, Illinois, was a rare and memorably named finding: the spiked helmet sign.
An ECG That Set Off Every Alarm
The man arrived at a rural hospital with two days of upper abdominal pain radiating to his back. He had a known history of alcohol misuse, high triglycerides, and pancreatitis. His vital signs were normal at first, and his exam showed abdominal tenderness. His first ECG and troponin blood test, a marker of heart muscle damage, were also normal.
Overnight, his condition deteriorated. His abdominal pain worsened, his abdomen grew more swollen and firm, and he became tachycardic, meaning his heart was racing, and diaphoretic, meaning he was sweating heavily.
A repeat ECG showed severe, convex ST-segment elevation in the inferior and anteroseptal leads, with mirror-image depression in the lateral leads. The report described the tracing as worrisome for an acute, extensive heart attack. Emergency catheterization followed and found no blocked arteries.
The report concluded that the tracing represented the spiked helmet sign, an unusual pattern of ST-segment elevation seen in critically ill patients.
A Pattern Named After a Prussian Military Helmet
The sign was first described in 2011 by Laszlo Littmann and a colleague in a series of eight patients, none of whom had critical heart illness, according to a 2021 case report summarizing that work. Heart attacks were ruled out with blood markers, and the pattern was associated with rapid increases in pressure inside the chest or abdomen. On the tracing, the upward shift begins before the QRS complex, the main spike of each heartbeat, rather than after it, producing a dome topped with a sharp point. To cardiologists, the shape recalls the Pickelhaube, the spiked helmet of the Prussian and later German military.
A 2023 review in Reviews in Cardiovascular Medicine called the sign a rare ECG marker associated with an increased risk of lethal ventricular arrhythmias and sudden cardiac death. It has been reported alongside sepsis, gastrointestinal perforation, pneumonia with low blood oxygen, bleeding around the brain, pneumothorax, and other severe illnesses, according to a 2023 case report in the Pan African Medical Journal.
Researchers do not fully agree on what causes it. One hypothesis described in that report holds that the pattern is partly an artifact, produced when contractions of the diaphragm line up with heartbeats. Another, raised in a 2020 JACC: Case Reports paper, points to surges of sympathetic nervous system activity, noting that the sign appears in conditions such as takotsubo cardiomyopathy and brain hemorrhage. The 2023 review likewise attributed it to sympathetic hyperactivity.
Its link to pancreatitis is considered unusual, although scattered cases have been published. In the Journal of Indian College of Cardiology, for example, doctors described a 27-year-old man with chest and upper abdominal pain after a night of heavy drinking whose spiked helmet pattern was first diagnosed as a heart attack and treated with a clot-dissolving drug. Tests later showed acute pancreatitis. He developed multiple organ failure and died on his second day, and the authors called the association with pancreatitis very rare.
Why the Cath Lab Still Made Sense
The same issue of JACC: Case Reports carried a second spiked helmet case from Rutgers, titled in part "When ST-Segment Elevations Do Not Need the Cath Lab." In that report, a 45-year-old man in septic shock had a heart rhythm on the monitor that was initially read as ventricular tachycardia. The authors argued that recognizing the sign helped steer care away from unnecessary cardiac interventions and toward his underlying illness.
But recognizing the sign does not mean ignoring the possibility of a real heart attack. The 2021 report described an 84-year-old man whose spiked helmet sign accompanied a genuine blockage of the right coronary artery. Those authors wrote that reciprocal ST depression, the kind of mirror-image changes seen in the Illinois patient, should raise suspicion of a true heart attack.
That tension explains the decision to catheterize. With a sweating, deteriorating patient and a tracing that could not be safely dismissed, looking directly at the arteries was the way to rule out a blockage. The normal result shifted attention back to his pancreas.
What the Case Changes and What It Doesn't
The published summary does not describe the man's longer-term outcome, only that his ECG normalized within six hours. A single case also cannot establish how often severe pancreatitis produces this pattern.
For clinicians, the takeaway is that a frightening ECG in a critically ill patient may reflect the underlying illness as much as the heart. For patients, none of this changes basic advice. Chest pain or pressure, shortness of breath, or a sudden cold sweat should be treated as a possible heart attack, and anyone with those symptoms should call 911 rather than wait to see whether an ECG turns out to be misleading.
Key Questions Answered
What is the spiked helmet sign?
It is an unusual ECG pattern of ST-segment elevation shaped like a dome with a sharp spike, named after the Prussian Pickelhaube helmet. It is typically seen in critically ill patients and was first described in patients without critical heart disease.
What happened to the patient in this report?
A 42-year-old man with recurrent pancreatitis developed ECG changes resembling an extensive heart attack. Emergency catheterization showed normal coronary arteries, and his ECG normalized after six hours.
Why did doctors still perform a heart catheterization?
The tracing looked like a major heart attack, and the spiked helmet sign can occasionally accompany a real blockage. Catheterization was the definitive way to rule one out.
Is the spiked helmet sign dangerous?
The sign reflects severe underlying illness. A 2023 review linked it to an increased risk of lethal heart rhythms and sudden cardiac death, which is why doctors treat it as a signal to search for the underlying cause.
Should people with chest pain assume their ECG might be misleading?
No. Anyone with chest pain, pressure, shortness of breath, or a sudden cold sweat should call 911. Only clinicians can sort out a true heart attack from a mimic.
