Coronary vasospasm (CV) is a rare cause of malignant ventricular arrhythmia and cardiac arrest. It typically presents with chest pain and marked ST-segment elevation. We present the case of a 61-year-old man with recurrent malignant ventricular arrhythmia and implantable defibrillator shocks without preceding chest pain. The diagnosis of CV remained elusive for 3 months despite extensive investigation. Close inspection of telemetry revealed progressive ST-segment depression and T-wave inversion before arrest. Coronary angiography with low-dose acetylcholine testing revealed multivessel vasospasm. Vasodilator therapy was initiated with rapid elimination of ventricular arrhythmia. This case highlights that cardiac arrest due to CV may present without the classical features of chest pain or ST-segment elevation, underscoring the value of provocation testing in unexplained arrhythmia. CV may present without preceding angina or ST-segment elevation. Careful electrocardiogram review and early provocation testing can identify vasospasm and guide therapy.