CCE-CE-006.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Task 1: Take an appropriate history, including cardiovascular risk factors, lifestyle habits, and family history.

The competent candidate should:

• Elicit cardiovascular risk factors, including:
  • Smoking status (5 cigarettes per day).
  • Alcohol intake (social drinking on weekends).
  • Dietary habits (processed foods, takeaway meals).
  • Physical activity levels (sedentary job, occasional exercise).
  • Weight and BMI changes.
• Explore relevant medical history, including:
  • Hypertension or diabetes (previous screenings, symptoms).
  • Any prior lipid profile results or history of hyperlipidaemia.
• Assess family history, focusing on:
  • Father’s myocardial infarction at 52, indicating genetic risk.
  • Any family history of stroke, peripheral vascular disease, or diabetes.
• Determine patient’s understanding and concerns:
  • What he knows about cholesterol.
  • Any beliefs about medications or lifestyle changes.

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Task 2: Explain the significance of a cholesterol level of 8.0, including cardiovascular risk assessment.

The competent candidate should:

• Explain lipid profile results in simple terms:
  • Total cholesterol (8.0 mmol/L) and LDL (5.6 mmol/L) are significantly high, increasing cardiovascular risk.
  • HDL (1.0 mmol/L) is low, which is less protective.
  • Triglycerides (2.1 mmol/L) are slightly elevated, often linked to diet and alcohol.
• Discuss cardiovascular risk assessment:
  • Calculate absolute cardiovascular risk using Australian CVD risk calculators.
  • Explain that a high LDL increases plaque build-up, leading to heart attacks and strokes.
• Address misconceptions:
  • “Even though you feel fine, high cholesterol is silent but increases your risk over time.”
• Explain the next steps:
  • Further tests (fasting glucose, HbA1c, blood pressure check).
  • Lifestyle modification and potential statin therapy.

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Task 3: Develop an individualised management plan, incorporating lifestyle modifications and medication.

The competent candidate should:

• Encourage lifestyle changes before considering medication:
  • Dietary modifications (reduce saturated fats, increase fibre and omega-3s).
  • Regular physical activity (at least 30 mins of moderate exercise most days).
  • Smoking cessation advice and support options (Quitline, NRT, behavioural therapy).
  • Alcohol reduction (limit to recommended guidelines).
• Consider pharmacological treatment (statins):
  • If absolute CVD risk >10%, statins are recommended.
  • If lifestyle changes fail to reduce cholesterol, statins may be necessary.
• Plan for follow-up:
  • Repeat lipid profile in 3 months.
  • Monitor for medication side effects if started.
  • Address adherence concerns with shared decision-making.

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Task 4: Address the patient’s concerns about cholesterol and treatment options.

The competent candidate should:

• Acknowledge patient concerns:
  • “I understand that taking a tablet every day is a big step. Let’s explore all options.”
• Provide evidence-based reassurance:
  • Statins reduce heart attack and stroke risk by 25-30%.
  • Common concerns like muscle aches are rare and manageable.
• Use a shared decision-making approach:
  • If patient prefers lifestyle changes first, offer 3-month review before deciding on medication.
  • Discuss long-term cholesterol management options.

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SUMMARY OF A COMPETENT ANSWER

• Takes a thorough cardiovascular risk history, including lifestyle and family history.
• Explains the significance of high cholesterol clearly, linking it to CVD risk.
• Uses an absolute cardiovascular risk approach to guide management.
• Develops a tailored lifestyle intervention plan before escalating to medication.
• Uses shared decision-making to address concerns about statins.

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PITFALLS

• Failing to assess full cardiovascular risk (e.g., ignoring family history or lifestyle factors).
• Over-emphasising cholesterol numbers without explaining real-life CVD risk.
• Not addressing patient concerns about medications, leading to non-compliance.
• Rushing into statin prescription without offering lifestyle modifications first.
• Using medical jargon instead of simple, patient-friendly explanations.

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REFERENCES

• Australian Cardiovascular Risk Calculator (Absolute CVD Risk Guidelines): Heart Foundation
• RACGP Guidelines for Lipid Management: RACGP
• Australian Dietary Guidelines – Healthy Eating for Heart Health: NHMRC
• Therapeutic Guidelines – Cardiovascular Risk Management: TG

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MARKING

Each competency area is assessed on a 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 Communicates effectively in explaining cholesterol risk.
1.3 Engages the patient in shared decision-making.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a full cardiovascular risk history.

3. Diagnosis, Decision-Making and Reasoning

3.1 Determines the need for statins based on CVD risk assessment.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a lifestyle-based management plan before prescribing.

5. Preventive and Population Health

5.1 Conducts cardiovascular risk assessment and prevention strategies.

6. Professionalism

6.2 Ensures patient-centred care while respecting autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate monitoring and follow-up.

9. Managing Uncertainty

9.1 Recognises when further investigations are needed.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies high-risk cardiovascular patients.

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Competency at Fellowship Level

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

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Familial Hypercholesterolaemia (FH): When to Consider It and Treatment Approach

Familial Hypercholesterolaemia (FH) is an autosomal dominant genetic disorder that leads to very high LDL cholesterol levels from birth and increased risk of premature cardiovascular disease (CVD). It is important to recognise when FH should be suspected and how it is managed, including the use of statins, ezetimibe, and PCSK9 inhibitors.

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When is Familial Hypercholesterolaemia (FH) Relevant?

FH should be suspected when a patient has:

Very high LDL-C:

• LDL > 6.5 mmol/L in adults (or >5.0 mmol/L if already on lipid-lowering therapy).
• Total cholesterol > 7.5 mmol/L, particularly in younger adults.

Personal or family history of premature cardiovascular disease (CVD):

• Personal history: Heart attack or stroke at ≤55 years (males) or ≤60 years (females).
• Family history: First-degree relative with heart attack, stroke, or revascularisation at a young age.

Physical signs (Less common in younger adults, but still important):

• Tendon xanthomas (Achilles, knuckles).
• Corneal arcus before age 40.

Genetic confirmation (if available but not essential for diagnosis):

• Pathogenic mutations in LDLR, APOB, or PCSK9 genes.

Risk Stratification in Primary Prevention (No CVD Yet)

• If LDL-C is >6.5 mmol/L, FH is very likely.
• If LDL-C is 5.0-6.5 mmol/L, assess family history and other risk factors.

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Management of FH: Do We Use Statins, Ezetimibe, and PCSK9 Inhibitors?

FH is always a high-risk condition, so treatment should be early, aggressive, and lifelong.

1. First-Line Therapy: Statins (ALWAYS INDICATED)

• High-intensity statins (e.g., atorvastatin 40-80 mg, rosuvastatin 20-40 mg) are first-line treatment.
• Statins reduce LDL by ~50% and significantly lower cardiovascular risk.
• Target LDL <2.6 mmol/L, or ideally <1.8 mmol/L if very high risk.

2. Second-Line Therapy: Ezetimibe (ADJUNCT TO STATINS)

• If LDL targets are not met despite maximum statin dose, add ezetimibe (10 mg daily).
• Ezetimibe reduces LDL by ~15-20%, working via cholesterol absorption inhibition.
• Combination statin + ezetimibe is well tolerated and effective in most FH patients.

3. Third-Line Therapy: PCSK9 Inhibitors (FOR VERY HIGH-RISK CASES)

• If statins + ezetimibe are not enough (e.g., LDL still >3.0 mmol/L in high-risk patients), add PCSK9 inhibitors (e.g., alirocumab, evolocumab).
• PCSK9 inhibitors lower LDL by 50-60% and are essential in severe FH cases or statin-intolerant patients.
• Very costly, PBS-subsidised only for certain high-risk groups in Australia.

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Key Takeaways for FH in the Context of This Case

• At total cholesterol of 8.0 mmol/L, FH is unlikely unless LDL is >6.5 mmol/L.
• If LDL is 5.6 mmol/L (as in this case), FH is possible but not definitive—check family history, physical signs, and consider genetic testing.
• Statins are the first-line treatment for high LDL, whether FH or not.
• Ezetimibe is added if LDL goals aren’t met on a statin alone.
• PCSK9 inhibitors are reserved for severe FH cases or statin intolerance.

Would you like me to expand on genetic testing or PBS criteria for PCSK9 inhibitors?