Mock 1 · Cholesterol

Persona and manner

• Articulate, confident, well-informed on her own terms; sees this as a debate she has prepared for; slightly condescending about 'the pharmaceutical model'.
• Underneath: frightened by her father's heart attack and by the number; she does not want to be told what to do, and she is genuinely open to numbers.

Opening line — say this verbatim

• "The nurse basically tried to hand me a statin prescription. I'm not against medicine, but I've read a lot about statins — the diabetes, the memory problems, the muscle damage — and I'd rather manage this naturally. I'd like to hear your honest view rather than the pathway."

Volunteer freely if given the space

• 'I eat better than anyone I know'; runs three times a week; 'no sugar'; 'red yeast rice is basically a natural statin anyway'.
• 'My dad's on five different tablets since his stents and he's never been the same.'

Only if asked

• Father: MI at 58, stents, alive, 'diminished'; uncle died at 52; grandmother 'heart' at 70. No one tested for familial hypercholesterolaemia; no known tendon xanthomata; her cholesterol 'has always been high — 6.8 five years ago'.
• No chest pain; no breathlessness; no claudication; no symptoms.
• Alcohol: wine four nights a week, 'a glass or two' — about 12 units. Sleep fine. Stress: 'a business to run'.
• Red yeast rice: two capsules a day for a year; she does not know it contains a statin-like compound (monacolin K) at an unregulated dose.
• Statins: 'I've read they cause diabetes in one in three, dementia, and everyone gets muscle pain.' She knows two clients 'who couldn't walk on them'.
• She would consider a statin 'if the numbers were compelling and it was my decision'; she would also accept 'a proper test for the family thing'.
• Menopause: perimenopausal, hot flushes, not on HRT — 'I manage it'.

Ideas, concerns and expectations

• Idea: 'diet and exercise will fix it; statins are over-prescribed'.
• Concern: her father's decline; dementia and diabetes from statins; 'being on tablets for life at 49'.
• Expectation: an honest discussion, a natural plan, and to be respected.

Cues to deliver, timed

• Minute 1: 'rather than the pathway.'
• Minute 4: 'he's never been the same' — about her father.
• Minute 8: 'if the numbers were compelling…'

How to respond to the doctor's plan

• If the doctor explores her beliefs and her father's story first, takes a family history that raises the possibility of familial hypercholesterolaemia (total cholesterol >7.5 or personal/family history of premature CHD — refer or apply Simon Broome/DLCN), explains QRISK in absolute terms she can use (14 in 100 over ten years; a statin roughly a quarter to a third fewer events — about 3–4 people per 100 helped), answers each statin belief with the evidence (new diabetes about 1 in 100 over 5 years, mostly in those already at risk; no evidence of dementia — if anything protective; muscle symptoms in trials no more common than placebo, with a nocebo effect), explains that red yeast rice is an unregulated statin, offers a genuine choice (lifestyle for three months with repeat lipids, or atorvastatin 20 mg with a 3-month check, or FH assessment first), agrees a plan with her, addresses alcohol and blood pressure, and safety-nets: she pauses — 'so the red yeast rice is a statin?' — and chooses the FH assessment with a trial of atorvastatin, 'on my terms'.
• If the doctor says 'the guideline says over 10% you should have a statin': 'that's exactly what the nurse said' — and she disengages.
• If the doctor agrees to 'natural management' without discussing FH or the numbers: she is pleased; the examiner is not.

Examination findings if requested

• BP 136/84; BMI 27; no xanthelasma; no tendon xanthomata; no corneal arcus; pulse 64.

Do not

• Volunteer the red yeast rice ingredient, the uncle's death age or the 5-year-old cholesterol unless asked.
• Concede quickly; she should be won by numbers and respect, not by authority.