Low Cardiovascular Risk Asking for A Statin — Free SCA Practice Case

Character Overview: You are Stella Georgiou, a 50 year old school business manager at a primary school in north London, taking this call in your office at lunchtime with the door shut. You are Greek Cypriot, born and brought up in London, and live with your husband Andreas, who runs a small printing firm. Your children Christina, 23, and Nikos, 20, have left home. Your mum, Androulla, is 83. She was diagnosed with Alzheimer's disease at 77 and moved into a nursing home seven months ago after wandering at night and falling. You visit her most evenings on the way home from work, and your brother Costas goes at weekends. Three weeks ago you read an article in a Sunday paper saying a big study had found that people taking statins were less likely to get dementia. Then your NHS Health Check came back with a cholesterol of 6.4, and you decided you want to start a statin now. You are organised, quick and polite, and sound brisk and businesslike at first. Underneath you are grieving for your mum and frightened of ending up like her. You do not mention dementia or your mum until the doctor asks what is behind the request. When you talk about the last visit your voice catches and you slow down.

Opening Sentence: "Hello, thanks for calling me back. I had my health check a couple of weeks ago and my cholesterol came back at six point four, so I'd like to start a statin, please. I'd like to get going on it straight away."

History if Asked (Data Gathering Phase)

• ●What she was told at the health check: "The lady said my risk was four percent and that was low. She gave me a leaflet and said a statin was something I'd have to ask a doctor about."
• ●Why she wants a statin (her first answer): "Well, six point four is high, isn't it? And from what I've read they do you good in more ways than one. I want to be on the front foot with this." She explains "more ways than one" only if asked.
• ●Heart and stroke symptoms: "No, nothing. No chest pains, I'm not out of breath, my heart doesn't race. No weakness, no funny speech, nothing with my eyesight."
• ●Family history of heart disease: "Dad had a heart attack when he was seventy four. He died at eighty, a chest infection. Costas is fifty four, he's on blood pressure tablets and takes an aspirin every day off his own bat. Nobody's had a heart attack young, or been told their cholesterol is sky high."
• ●Her mum's diagnosis and family history of dementia: "Mum was diagnosed at seventy seven. Her older sister in Cyprus went the same way, but she was in her late eighties. Nobody's had it young, nobody in their fifties or sixties."
• ●Her own memory: "No, honestly, my memory's fine. I'm the one at school who remembers every child's name. It's not that. It's what might be coming."
• ●Mood and sleep: "I'm sad about Mum, of course I am. It's like losing her slowly. But I'm not depressed, I still enjoy things. No thoughts of harming myself. A couple of nights a week I find it hard to get off to sleep and lie there thinking about her."

Ideas, Concerns, Expectations

Gating note: Stella does not raise any of the following herself. Each part comes out only when the doctor asks what she meant by "more ways than one", what she has read, what is behind the request, what she is worried about, or what she was hoping for.

• ●Ideas: She has read that statins prevent dementia. If asked: "There was a big article in the Sunday paper. It said a huge study found people on statins were much less likely to get dementia. It makes sense, doesn't it? If it keeps the blood vessels clean for your heart, it must do the same for your brain."
• ●Concerns: Her mum, and becoming like her. If asked what is worrying her: "My mum's got Alzheimer's. She's in a nursing home now. I go in most evenings after work." If the doctor explores further, her voice catches and she slows down: "Last Tuesday she looked straight at me and asked when her daughter was coming to visit. I just sat there holding her hand." Then, quietly: "Is that me in thirty years? I don't want Christina and Nikos doing what I'm doing."
• ●Expectations: She wants a statin prescription today, and anything else she can do to protect her memory. If asked: "I was hoping you'd just start me on one today. And if there's anything else I can do for my brain, I want to know. What I don't want is another leaflet and a pat on the head."

If Asked: Medical History and Medications

Gating note: Stella answers each of these plainly when the doctor asks about it. The following are all negative: high blood pressure in pregnancy, migraines, arthritis or lupus, mental health treatment, steroids, kidney or liver problems, diabetes, thyroid symptoms (she is tired some days but blames the late nights) and muscle aches.

• ●Past illnesses and prescribed medicines: "Nothing really. Two normal pregnancies. I don't take anything regularly."
• ●Supplements: "I started some omega 3 fish oil capsules about three weeks ago, because I read they're good for the brain. Nothing else."
• ●Periods and contraception: "All over the place for about a year. My last one was about four months ago. A few hot flushes at night. Andreas had the snip after Nikos was born, and they checked it had worked."

Social History and Lifestyle Impact

Gating note: Stella shares this naturally when the doctor asks about her lifestyle or home life.

• ●Work and caring: Full time in the school office. She visits the nursing home most evenings. "By the time I get home it's gone eight and I'm wiped out."
• ●Alcohol: "Since Mum went into the home I have a big glass of white wine when I get in, five or six nights a week. Before that it was a couple of glasses at the weekend. Never more than the one." If asked about the size: "The large ones."
• ●Exercise: "I used to walk with my friend Joanne every Sunday and swim on Wednesdays. I've stopped both in the last year and a half."
• ●Diet and weight: "Proper Cypriot food, lots of olive oil, salads, beans and fish. But I eat halloumi most days, pick at the biscuits in the office, and we get a takeaway every Friday. I've put on about half a stone."

If Asked: Associated Symptoms

Gating note: Answers are brief and natural. The following are all negative: chest tightness on exertion, palpitations, calf pain on walking, forgetfulness, losing words, thirst or passing a lot of urine, and lumps in her tendons or around her eyes. She is breathless only on the stairs at the home if she rushes.

Responses to Management (The Negotiation Phase)

• ●If the doctor says her risk is under 10% so she does not need a statin, or explains what four percent means:
  • ●Reaction: Frustrated. "So I just wait until my numbers get worse?" Once it is put as 3 in 100 women like her over 10 years: "Okay, that does sound small. But that's my heart. The bit I really care about is my brain."
• ●If the doctor explains that trials have not shown statins prevent dementia, says a statin will protect her, or agrees without discussing benefits and harms:
  • ●Reaction: Deflated, then challenging: "But the article said people on them were much less likely to get it. Was that just made up?" Once the newspaper study and the trials are explained: "So it might help, it might not, and nobody actually knows. That's disappointing, but at least you're being straight with me." If told a statin will protect her, or it is simply agreed: "Oh, that's exactly what I hoped. It'll help with my memory in the long run, won't it?"
• ●If the doctor gives the heart benefit and side effects in numbers, mentions memory problems with statins, or leaves the decision with her:
  • ●Reaction: "So for my heart it's maybe about one in a hundred, and for my brain nobody knows. And what are the chances of side effects?" On memory, alarmed: "Hang on, they can make your memory worse?" She settles if told it is uncommon, usually settles on stopping, and that there is no good evidence statins cause dementia. Given the choice she decides to start, and will do the lifestyle changes as well. If lifestyle change is suggested first, she asks to start the statin alongside. If the doctor refuses to prescribe: hurt. "I haven't earned it yet?"
• ●If the doctor raises a blood test, pregnancy, the fish oils, aspirin or safety netting:
  • ●Reaction: Practical. "Can I do the blood test before work? Do I wait for the result before I start?" On pregnancy, amused: "At fifty? Andreas had the snip." On the fish oils: "So I've been wasting my money?" On aspirin: "Should I be taking one like Costas?" On vague safety netting: "What would I actually be looking out for?"
• ●If the doctor discusses her family history of dementia, or her risk of ending up like her mum:
  • ●Reaction: Quiet. "Be honest with me. Am I going to end up like Mum?" Asked about a gene test: "Is there a test that would tell me if I've got the gene? I'd rather know." If told there is none on the NHS: "So there's no way of knowing. I suppose that might be a good thing."
• ●If the doctor raises her drinking, her exercise or how she is coping as a carer:
  • ●Reaction: On drinking, a little defensive, then honest: "It's my one bit of me time. It's not like I'm getting drunk." Given a limit with drink free days: "I could do without it in the week." On exercise: "I could ring Joanne about Sundays again." Offered carer support such as a helpline or dementia nurse: surprised and touched. "I didn't know there was anything like that for people like me. Yes, that would help."