With this foreign body, typical patient complaints are odynophagia and dysphagia. After reviewing the patient’s symptoms again, it was discovered that on the same day as the onset of symptoms he had eaten a fish meal and 3 h later went for a walk. The event occurred during Holy Week, in which Catholics can only eat fish. However, in the present patient the typical GI complaints of esophageal perforation were absent, and the tract of the foreign body was unusual. After perforating the esophagus, the fishbone moved anteriorly, bypassing the aorta, perforating the pericardium, and injuring the right ventricular myocardium. Therefore, the elevated cardiac enzyme levels were secondary to mechanical trauma of the myocardium and not to an ischemic event. The literature reports seven cases of esophagopericardial fistulas, with two occurring because of fish bones. More than 100 cases of aortoesophageal fistulas have been reported to have an association with esophageal perforation by fish bones. Because of the patient’s risk factors, elevated troponin levels, and abnormal ECG findings, the initial impression was acute coronary syndrome with post-myocardial infarction pericarditis. Once the transesophageal echocardiogram did not demonstrate acute aortic dissection, the patient received treatment with aspirin, anticoagulation, β-blockers, and nitroglycerin. This treatment interfered with the coagulation pathways and ultimately led to cardiac tamponade.