Unfolding Case Study: Cardiovascular Pharmacology in Primary Care
Case: Mr. Marcus Rodriguez
Primary care visit — Tuesday morning, 9:15 AM
Initial Presentation
Marcus Rodriguez is a 54-year-old man who called your office first thing this morning and was fit in as an urgent visit. He is a high school football coach, a former smoker (quit 8 years ago), and is moderately active. His medical history includes hypertension (on lisinopril 10 mg and amlodipine 5 mg daily) and type 2 diabetes (on metformin 1000 mg BID). He had a routine visit 6 months ago with no concerns.
He presents today with a 2-day history of sharp chest pain. He describes it as worse when he lies down to sleep and better when he sits up and leans forward over his desk at work. He also reports having had a bad cold with a low-grade fever and runny nose about 12–14 days ago. He thought he was over it, but the chest pain started 2 days later.
He denies radiation of the pain to his jaw or left arm. He has no dyspnea at rest. He took ibuprofen twice yesterday and it helped somewhat.
Physical Exam:
Cardiac: Regular rate, S1/S2 intact. A scratchy, high-pitched, three-component sound audible at the left lower sternal border, best heard when the patient leans forward. No S3 or S4.
Lungs: Clear to auscultation bilaterally
Extremities: No edema
JVP: Not elevated
ECG (in office):
Sinus rhythm at 88 bpm. Diffuse saddle-shaped ST elevation in I, II, III, aVF, V2–V6 with PR-segment depression in multiple leads. No reciprocal changes. No Q waves.
CRP (rapid): 54 mg/L (elevated). Troponin I (rapid): 0.03 ng/mL (upper limit of normal: 0.04 ng/mL).
Decision Point 1 of 5
Based on Mr. Rodriguez’s presentation, ECG findings, and clinical context, what is the most appropriate immediate diagnosis and initial action?
Case Continues — 20 Minutes Later
You have diagnosed acute pericarditis and ordered additional labs
Results return while Mr. Rodriguez is still in the office
You send labs while educating Mr. Rodriguez about pericarditis. He is relieved it is not a heart attack. His CBC shows mild leukocytosis (WBC 11.2). ESR is 68 mm/hr. Thyroid function is normal. Comprehensive metabolic panel is unremarkable with creatinine 0.9 mg/dL and potassium 4.3 mEq/L. A second troponin drawn 1 hour after the first is 0.03 ng/mL (unchanged — no rising pattern).
Mr. Rodriguez weighs 89 kg (196 lbs). He has no history of peptic ulcer disease, renal impairment, or hypersensitivity to NSAIDs. He is not pregnant. He asks: “What are you going to give me to make this better?”
Decision Point 2 of 5
Which treatment regimen is most appropriate for Mr. Rodriguez’s first episode of acute pericarditis?
Case Continues — End of the Visit
Treatment plan established — counseling Mr. Rodriguez
Before Mr. Rodriguez leaves the office
You have written the prescriptions. Mr. Rodriguez is feeling somewhat better just knowing what is wrong. He is very active — as a football coach he runs practice drills, lifts weights 4 days per week, and plays in a weekend recreational basketball league. He is feeling about 60% of his usual self right now.
“Can I still run practice tomorrow?” he asks. “I mean, I’m not going to run sprints or anything. I’ll just be watching and maybe doing some light drills with the quarterbacks. And the basketball league has playoffs in 3 weeks — I really want to make that.”
Decision Point 3 of 5
How do you counsel Mr. Rodriguez regarding physical activity?
Case Continues — 3-Week Follow-Up Visit
Mr. Rodriguez returns to see how he is doing
Three weeks later
Mr. Rodriguez returns as scheduled. He reports his chest pain is about 90% resolved — he still notices it occasionally when he lies flat to sleep but it is mild. He has been taking ibuprofen and colchicine as prescribed and started the omeprazole. He has not exercised, which has been difficult for him.
He is eager to resume activity and is asking about the basketball playoffs, which start in 4 days.
Today’s labs: CRP is 18 mg/L (still elevated; was 54 mg/L at diagnosis). Repeat ECG is normal sinus rhythm with resolving but still present diffuse ST changes.
Clinical note: His chest pain is 90% resolved, but his CRP remains elevated at 18 mg/L (normal <3 mg/L) and his ECG still shows ST changes. He continues to have residual symptoms.
Decision Point 4 of 5
Mr. Rodriguez feels much better and wants to return to basketball in 4 days. The basketball season ends after playoffs. What is your management?
Case Continues — 9 Months Later
Mr. Rodriguez is back — and not happy about it
9 months after the initial episode
Mr. Rodriguez was cleared for activity 5 weeks after his initial presentation when his CRP finally normalized. He completed his full 3-month colchicine course and had no further symptoms. Then, 9 months after the initial episode, he calls in with a familiar story: the same sharp, positional chest pain that is worse lying flat and better leaning forward, onset 2 days ago. He has been well and had no viral illness this time.
You bring him in. Examination reveals a faint friction rub. ECG shows the same diffuse saddle-shaped ST elevation pattern as before. CRP is 42 mg/L. Troponin is negative. He is frustrated: “I thought the colchicine was supposed to prevent this.”
This is his second episode. He completed his full first-line course. He has no renal impairment or GI contraindications.
Decision Point 5 of 5
Mr. Rodriguez has his first recurrence of pericarditis, 9 months after the initial episode, having completed a full course of NSAIDs and colchicine. Which management approach is most appropriate?