Cases/Cardiovascular Health

High Cholesterol Intolerant of Statins and Ezetimibe, Afraid of Needles — Free SCA Practice Case

Man with high cholesterol intolerant of statins and ezetimibe, afraid of needles

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Raymond Clarke

Age

61 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My cholesterol's still high and I've had nothing but trouble with the tablets. The letter mentioned an injection but I need to tell you now — I can't do needles. I really can't."

Medical Records

●PMH: Myocardial infarction 2 years ago (stented, single vessel). Hypertension.
●Medications: Ramipril 5 mg OD, bisoprolol 2.5 mg OD, aspirin 75 mg OD. (Atorvastatin, then rosuvastatin — both discontinued for myalgia. Ezetimibe — discontinued, patient reported intolerance. Bempedoic acid trialled — stopped after side effects.)
●Allergies: NKDA.
●Recent results (fasting lipids 4 weeks ago): Total cholesterol 6.2, LDL-C 3.9 mmol/L, HDL 1.0, triglycerides 1.8. LFTs normal. Creatine kinase normal (checked off treatment). HbA1c 40 mmol/mol.
●Recent note: Lipid clinic letter suggests considering inclisiran or a PCSK9 inhibitor given documented intolerance to statins, ezetimibe and bempedoic acid, with LDL-C persistently above target for secondary prevention.

Patient Script

For the friend playing the patient role

Character Overview: You are Raymond, a 61-year-old retired postman. You are polite but weary — you feel you have "tried everything" and each medication has caused a problem. You are genuinely and specifically frightened of needles; this is not a throwaway comment. You have avoided blood tests for years and only had the recent one because a nurse talked you through it. You want your heart protected but the idea of an injection makes you feel sick.

Opening Sentence: "Morning, Doctor. So the hospital letter says my cholesterol's still too high after my heart attack, and they mentioned some sort of injection. I'll be honest with you — I've got a real thing about needles. Always have. I nearly didn't come to this appointment."

History if Asked (Data Gathering Phase)

●The statins: "First one — atorvastatin — gave me terrible aches in my thighs and shoulders within a few weeks. They swapped me to rosuvastatin and it was the same, maybe a bit less. I stopped both. The aches went once I was off them."
●Ezetimibe: "That was a tablet too — I tried it but I felt rough on it, stomach upset, so I came off it."
●Bempedoic acid: "Another tablet. Didn't get on with it either — more of the achy stuff. So here we are."
●The heart attack: "Two years ago. Had a stent put in. Frightened the life out of me. I know I need to look after my heart, that's the thing."
●The needle fear: "It's not that I'm being difficult. I go faint. I've fainted having blood taken before. I put off that recent blood test for months."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Raymond assumes an "injection" means something he would have to do to himself, at home, regularly — like insulin — and that thought is unbearable to him. He does not know that different injectable options differ hugely in how often, and by whom, they are given. "When they say injection I picture jabbing myself every day like a diabetic. I couldn't do that. Is that what it is?"
●Concerns: Underneath the needle fear is real anxiety about his heart — he knows his cholesterol is a risk after the heart attack and he does not want another one. He feels stuck between two frightening things. "I don't want another heart attack, that's the honest truth. But the needle — I don't know how I get past that."
●Expectations: He is hoping there might be another tablet he hasn't tried, or that the whole injection idea can be avoided. He wants to be reassured he is not being written off. "I suppose I'm hoping you'll say there's a pill I've not had yet. I don't want to feel like I've run out of options."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Heart attack and stent: "Two years ago, one stent, single blockage they said. Been on the tablets for my heart since."
●Current medications: "Ramipril, bisoprolol, and a baby aspirin. I take those fine — they're not the problem."
●Blood pressure: "That's been alright, well controlled they tell me."
●Muscle symptoms now: "No aches at the moment, now I'm off all the cholesterol stuff."
●Family history: "My father had a heart attack in his fifties. So it runs in the family, doesn't it."

Social History and Lifestyle Impact

Raymond is a retired postman. He lives with his wife. He has cut down considerably since his heart attack.

●Diet and lifestyle: "I changed a lot after the heart attack — cut the fry-ups, walk the dog every day, don't smoke, barely drink now. I've done my bit on that front."
●Impact of the needle fear: "It sounds daft at my age but it genuinely stops me. I've skipped tests I should've had. My wife has to come with me for blood tests."
●Support: "The wife's very good. She'd come to appointments if it helped."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about current muscle aches: "None now — that all cleared once I stopped the tablets."
●If asked about chest pain since the heart attack: "No, no chest pain. The stent sorted that."
●If asked about breathlessness or ankle swelling: "No, none of that."
●If asked about how the statin aches felt (to characterise them): "Deep aching in the big muscles — thighs, upper arms, both sides. Not weakness exactly, just achy and heavy. Worse with the first statin."
●If asked about dark urine or severe weakness (to exclude serious myopathy): "No, nothing like that. No dark wee, no proper weakness. Just the aches."
●If asked about whether the aches were ever checked with a blood test: "They did take blood once for it — said the muscle level was normal, I think."

Responses to Management (The Negotiation Phase)

●If the Doctor explains inclisiran is given twice a year by a nurse: "Twice a year? And the nurse does it, not me? That's... that's not what I was picturing at all. Twice a year I could maybe cope with." (The tested point is whether the candidate correctly explains that inclisiran is a clinician-administered subcutaneous injection given at outset, again at around three months, then roughly every six months — a very different proposition from daily self-injection.)
●If the Doctor suggests re-trying a statin at low dose or alternate days: "Go back on the statins? But they gave me those awful aches. Why would it be different this time?"
●If the Doctor mentions PCSK9 inhibitors: "How often is that one? Would I have to do that one myself?"
●If the Doctor offers to help with the needle fear: "Is there anything that actually helps with the fear, or do I just have to grin and bear it?"
●If the Doctor explains why lowering the cholesterol matters after his MI: "So if I don't get this sorted, what are we actually talking about — another heart attack?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Lipid Targets in Secondary Prevention

●After established cardiovascular disease (here, a prior MI), the aim is substantial LDL-lowering to reduce recurrent events. NICE NG238 sets an ambition of a large reduction in non-HDL/LDL cholesterol, with specialist pathways using LDL-C targets (commonly LDL-C below 2.0 mmol/L or non-HDL below 2.6 mmol/L) for high-risk secondary prevention.
●An LDL-C of 3.9 mmol/L two years after an MI is well above target and represents meaningful residual risk that should be actively addressed.

Assessing "Statin Intolerance" Before Accepting It

●Statin-associated muscle symptoms are common and usually benign; true severe myopathy or rhabdomyolysis (marked weakness, very high creatine kinase, dark urine) is uncommon.
●Before labelling a patient statin-intolerant, characterise the symptoms (site, symmetry, timing, resolution on stopping), check creatine kinase, and exclude other causes (hypothyroidism, drug interactions).
●Many patients tolerate a lower dose, a different statin, or an alternate-day/twice-weekly regimen. Even a low dose of statin provides worthwhile benefit and should be pursued before moving on.

The Ordered Oral Pathway

●Standard oral escalation: maximise a tolerated statin, then add ezetimibe, then consider bempedoic acid (often combined with ezetimibe) where statins are not tolerated.
●Injectable therapies are considered when oral options are genuinely exhausted and LDL-C remains above threshold in an eligible patient.

Inclisiran — What It Is and How It Is Given

●Inclisiran is a small interfering RNA (siRNA) therapy that reduces hepatic PCSK9 production, lowering LDL-C.
●It is a subcutaneous injection administered by a healthcare professional: an initial dose, a further dose at around 3 months, then approximately every 6 months thereafter.
●NICE TA733 recommends inclisiran as an option in adults with established atherosclerotic cardiovascular disease and persistently high LDL-C despite maximum tolerated lipid-lowering therapy.
●The twice-yearly, clinician-administered schedule is the crucial point for a needle-phobic patient: it is a world away from daily self-injection.

PCSK9 Inhibitors — The Alternative Injectable

●Alirocumab and evolocumab are monoclonal antibodies against PCSK9, self-administered subcutaneously every 2–4 weeks.
●NICE TA393/TA394 set the LDL-C thresholds for funding, which differ between primary prevention, secondary prevention, and familial hypercholesterolaemia.
●For a patient with severe needle phobia, the frequent self-injection burden makes inclisiran the more acceptable option — but the choice should be informed and shared.

Managing Needle Phobia Practically

●Needle phobia is common and can lead to avoidance of essential care (blood tests, vaccinations, injectable treatment).
●The applied-tension technique (tensing the large muscles to raise blood pressure) helps prevent the vasovagal faint that many needle-phobic patients fear.
●Practical measures: a calm, unhurried appointment; lying down; a trusted person present; distraction; and, for severe phobia, graded exposure or referral for psychological support.
●Choosing the least burdensome effective option (here, twice-yearly inclisiran) is itself part of managing the phobia.

Optimising the Whole Secondary-Prevention Package

●Lipid management sits alongside antiplatelet therapy, blood-pressure control, glycaemic control, smoking cessation, cardiac rehabilitation, and physical activity.
●Review adherence to the whole regimen; residual risk is reduced most by attending to all components, not the cholesterol alone.

Monitoring and Follow-Up

●Recheck lipids after starting or changing therapy to confirm the LDL response (timing depends on the agent).
●Arrange follow-up to review tolerability and adherence, and refer or arrange shared care in line with the local pathway for injectable lipid-lowering therapies.

Common Candidate Mistakes in This Case

●Accepting "statin-intolerant" at face value: not attempting a low-dose or alternate-day rechallenge, and so abandoning the most evidence-based therapy prematurely.
●Describing the injection inaccurately: failing to explain that inclisiran is nurse-given twice a year, and so missing the fact that resolves the patient's central fear.
●Not distinguishing the injectables: presenting "an injection" as a single option without contrasting twice-yearly inclisiran with fortnightly self-injected PCSK9 inhibitors.
●Ignoring or minimising the phobia: offering no practical help, leaving a patient who nearly did not attend without a way forward.
●Skipping eligibility and pathway: offering an injectable with no reference to NICE criteria or the local referral/shared-care route.

Free MRCGP SCA practice case for GP registrars covering High Cholesterol Intolerant of Statins and Ezetimibe, Afraid of Needles — Cardiovascular Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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