Acute myocardial infarction secondary to patent foramen ovale

A 32-year-old female presented with severe chest pain after few episodes of vomiting day after 5 h skiing and few alcoholic beverages consistent with ST-segment elevation myocardial infarction. Coronary angiography showed multiple complete distal obstructions including LAD, OM1 and OM2. Recovery was uneventful until 3rd day in our clinic when subsequent chest pain and vomiting occurred. Repeated vomiting and chest pain and new documented ST-segment elevation on ECG with a history of 5 h long skiing, made us look for paradoxical embolism. This intention was directed by MINOCA algorithm as one of the causes of epicardial/microvascular obstruction is paradoxical shunting. This case depicts our diagnostic approach to patent foramen ovale.