Acute ECG changes in a woman presenting to coronary care with fluctuating consciousness

We present the case of a 67-year-old woman brought into the coronary care unit (CCU) with a suspected ST-segment elevation myocardial infarction (STEMI) due to lateral ST-segment elevation on her 12-lead electrocardiogram (ECG) and a significant troponin rise, but no reported chest pain and a fluctuating consciousness level. Whilst in CCU, she deteriorated further with a reduction in consciousness and sluggish pupillary reflexes, warranting urgent computed tomography (CT) of her brain, which confirmed extensive subarachnoid haemorrhage (SAH) with early evidence of hydrocephalus. She was therefore transferred to the local tertiary neurosurgical centre for endovascular coiling. ECG changes alongside a raised troponin are not uncommon findings in SAH and clinicians should exercise vigilance and consider urgent brain imaging in the absence of chest pain and presence of neurological deficit, to prevent adverse events from unnecessary antiplatelet or anticoagulant therapy, and invasive coronary angiography. SAH is a medical emergency and prompt recognition and referral for neurosurgical intervention is integral for optimal patient outcome.