CCE-CBD-029.1

Examiner Only Information

Questions

Q1. How would you explain Robert’s condition and its significance?

• Prompt: How do you explain ischaemic heart disease in simple terms?
• Prompt: What are the risks of angina progressing to a heart attack?

Q2. What investigations would you order to confirm the diagnosis and assess risk?

• Prompt: What baseline tests should be done?
• Prompt: When would you refer for an exercise stress test or coronary angiography?

Q3. What are the key components of Robert’s management plan?

• Prompt: What medications should be initiated or adjusted?
• Prompt: What lifestyle changes would you recommend?

Q4. How would you educate Robert on recognising and responding to worsening symptoms?

• Prompt: When should he seek urgent medical attention?
• Prompt: How would you explain the role of GTN (glyceryl trinitrate)?

Q5. When would you refer Robert to a cardiologist?

• Prompt: What clinical features suggest the need for specialist input?
• Prompt: When is revascularisation (angioplasty or bypass) considered?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you explain Robert’s condition and its significance?

The competent candidate should:

• Explain ischaemic heart disease (IHD) in simple terms:
  • “IHD occurs when the arteries supplying blood to the heart become narrowed due to plaque buildup, reducing oxygen supply to the heart muscle.”
  • “This can cause symptoms such as chest tightness, particularly with exertion.”
• Differentiate stable angina from acute coronary syndrome (ACS):
  • “Your symptoms suggest stable angina, which occurs predictably with exertion and improves with rest.”
  • “This differs from a heart attack, which causes severe, prolonged pain and may not resolve with rest.”
• Discuss the risks:
  • “Angina is a warning sign of underlying heart disease. Without treatment, the risk of heart attack or other complications increases.”
  • “However, with the right lifestyle changes and medications, we can significantly reduce this risk.”

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Q2: What investigations would you order to confirm the diagnosis and assess risk?

The competent candidate should:

• Baseline tests to confirm IHD and assess risk factors:
  • ECG (to check for previous infarcts, conduction abnormalities).
  • Echocardiogram (to assess heart function and wall motion abnormalities).
  • Lipid profile, HbA1c, renal function tests (to assess cardiovascular risk).
  • Troponin (if concern for ACS).
• Functional testing for IHD diagnosis:
  • Exercise stress test (if symptoms need further confirmation).
  • CT coronary angiography (if high suspicion or unclear diagnosis).

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Q3: What are the key components of Robert’s management plan?

The competent candidate should:

• Medications for symptom relief and long-term risk reduction:
  • Short-acting nitrates (GTN spray or tablets) for symptomatic relief.
  • Beta-blockers or calcium channel blockers (for heart rate control and angina prevention).
  • Aspirin + statin (for cardiovascular protection).
  • ACE inhibitor (if high risk or concomitant hypertension).
• Lifestyle modifications:
  • Smoking cessation support (e.g., nicotine replacement therapy, Quitline referral).
  • Weight management and Mediterranean-style diet.
  • Regular exercise (walking 30 minutes most days).

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Q4: How would you educate Robert on recognising and responding to worsening symptoms?

The competent candidate should:

• Recognising red flags for ACS:
  • “Seek immediate medical help if you experience chest pain at rest, increasing frequency of angina, or pain not relieved by GTN.”
• Proper use of GTN:
  • “Use GTN spray under the tongue if chest tightness occurs. If symptoms persist after 5 minutes, take another dose and call an ambulance if there is no relief after 2 doses.”

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Q5: When would you refer Robert to a cardiologist?

The competent candidate should:

• Urgent referral if:
  • Angina is increasing in frequency or severity (possible unstable angina).
  • High-risk features on ECG or stress testing.
• Routine referral if:
  • Considering coronary angiography or revascularisation (stenting or bypass surgery).

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SUMMARY OF A COMPETENT ANSWER

• Explains IHD and differentiates stable angina from ACS.
• Orders appropriate investigations, including ECG and functional tests.
• Initiates evidence-based medical therapy and lifestyle interventions.
• Educates on GTN use and recognising symptoms of a heart attack.
• Refers to cardiology when needed for further assessment or intervention.

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PITFALLS

• Failing to assess ACS risk and missing red flag symptoms.
• Not addressing smoking cessation and lifestyle modification.
• Omitting aspirin or statin therapy when indicated.
• Delaying cardiology referral for high-risk cases.

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REFERENCES

• RACGP Guidelines on Cardiovascular Risk Management
• National Heart Foundation on Angina and Ischaemic Heart Disease
• National Institutes of Health on Ischaemic Heart Disease

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Clearly explains IHD and its risks in understandable terms.

2. Clinical Information Gathering and Interpretation

2.1 Orders appropriate investigations for diagnosing IHD.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates stable angina from ACS and manages accordingly.

4. Clinical Management and Therapeutic Reasoning

4.1 Implements pharmacological and lifestyle interventions.

5. Preventive and Population Health

5.2 Focuses on risk factor modification (smoking, diet, exercise).

6. Professionalism

6.3 Provides patient-centred care, addressing concerns and expectations.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures appropriate documentation and referrals.

9. Managing Uncertainty

9.1 Recognises when to escalate care and refer for specialist input.

10. Identifying and Managing the Patient with Significant Illness

10.3 Detects and appropriately manages high-risk cardiac conditions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD