Background: Atypical presentation of Prinzmetal angina is a challenge to an astute emergency physician. Case Report: A 51 year male, known case of chronic kidney disease presented to Emergency Department (ED) with complaints of intermittent altered mental status since last 6 hours prior to ED arrival. In between patient was neurologically intact. Frequency of these episodes was gradually increasing. On ED evaluation patient was conscious, oriented and hemodynamically stable. Initial electrocardiogram (ECG) and biochemical markers did not show any abnormality. During next episode of altered mental status, ECG showed ST elevation in infero-posterior leads which returned back to normal sinus rhythm within 20 minutes. This was a case of Prinzmetal angina which can be missed easily, if not suspected. Conclusion: Awareness regarding existence of Prinzmetal angina is important to emergency physician.