Cases/Cardiovascular Health

Low Qrisk Score — Free SCA Practice Case

Man requesting a statin with a low QRISK score

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

Adam Reilly

Age

45 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My cholesterol came back at 6 and I want to go on a statin to sort it out. My mate's on one and I'd rather just deal with it now than wait for something to happen."

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.
●Recent results: Total cholesterol 6.0 mmol/L; HDL 1.3; non-HDL 4.7; LDL-C 3.8; triglycerides 1.2. HbA1c 36 mmol/mol. BP 124/78. BMI 25. LFTs and TFTs normal.
●Calculated QRISK3: 2.8% ten-year cardiovascular risk. Current smoker (~10/day).

Patient Script

For the friend playing the patient role

Character Overview: You are Adam, a 45-year-old software developer. You are health-conscious in a slightly anxious way — you have been reading about cholesterol online and you have decided a statin is the sensible, proactive move. You are articulate and will push back reasonably if told you do not need one. You are attached to the idea of the tablet and less keen to hear that stopping smoking would do far more. You are not in denial about the smoking, just resistant to being redirected.

Opening Sentence: "Hi Doctor. So my cholesterol's come back at 6, which sounds high to me, and I've done my reading — I'd like to start a statin. I'd rather be proactive and get ahead of it than sit around waiting to have a heart attack like my uncle did."

History if Asked (Data Gathering Phase)

●Why he wants the statin: "Six sounds high. My mate the same age is on one and swears by it. I'd just feel like I was doing something about it."
●The uncle: "My uncle had a heart attack, but he was in his late sixties and he was a big bloke, didn't look after himself. My dad's fine, my mum's fine."
●Smoking: "Yeah, I smoke — about ten a day. I know, I know. But loads of people smoke and don't have heart attacks, don't they?"
●General health: "I'm fit enough. I go to five-a-side once a week. No chest pain, no problems. I feel well."
●Diet: "Reasonable, I'd say. Could be better. I don't eat loads of junk."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Adam believes a cholesterol of 6 is dangerous in itself and that a statin is the obvious fix — he thinks of cardiovascular risk as being mostly about the cholesterol number. "In my head, 6 is the problem, and the statin brings it down, job done. That's how it works, isn't it?"
●Concerns: Underneath is a real anxiety about dying early of a heart attack like his uncle; the statin request is partly a way of managing that fear. "I suppose I don't want to drop dead at sixty. My uncle's heart attack shook me up more than I let on."
●Expectations: He expects to leave with a statin prescription and may feel fobbed off if simply told no. "Honestly, I came in expecting to walk out with a prescription. I don't want to be told to just come back in five years."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Past medical history: "Nothing. Never been on any regular medication."
●Blood pressure: "They took it just now — said it was fine."
●Diabetes: "No, no diabetes. My sugar was checked, came back normal I think."
●Family history (detail): "The uncle's on my mum's side, heart attack late sixties. No one's had anything young, no sudden deaths, nothing like that."
●Allergies: "None."

Social History and Lifestyle Impact

Adam is a software developer working mostly from home. He lives with his partner and their young child.

●Smoking: "Ten a day, been smoking since uni. I've tried to stop a couple of times — vaping, patches — never quite stuck."
●Alcohol: "A few beers at the weekend, nothing over the top."
●Exercise: "Five-a-side football once a week, bit of walking. Desk job otherwise."
●Diet and weight: "Weight's okay, BMI's about 25 they said. Diet's alright, not perfect."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about chest pain or exertional symptoms: "No, nothing. I run around at football fine."
●If asked about breathlessness: "No, no issues."
●If asked about tendon xanthomata / lumps around tendons or eyes (FH signs): "No, I've not noticed any lumps or anything like that."
●If asked about family history of very high cholesterol or early heart disease: "Not that I know of. No one's been told they've got sky-high cholesterol or had anything in their forties or fifties."
●If asked about symptoms of thyroid or other secondary causes: "No, I feel well, weight's steady, no other symptoms."

Responses to Management (The Negotiation Phase)

●If the Doctor explains his QRISK is low and a statin is not routinely indicated: "But 6 is high, isn't it? How can my risk be low with a cholesterol of 6?" (The tested point is explaining that cardiovascular risk is a composite — a single cholesterol figure does not equal high risk — and that his calculated 10-year risk is low.)
●If the Doctor prioritises smoking cessation: "So you're telling me to quit smoking instead of giving me a tablet? That feels like a cop-out." (The tested point is conveying, without lecturing, that stopping smoking reduces his risk far more than a statin would at his level.)
●If the Doctor still offers a statin after shared discussion: "So I can have it if I really want it? What are the downsides?"
●If the Doctor mentions rechecking and excluding familial causes: "You think it might be hereditary? Should I be worried about that?"
●If the Doctor addresses his fear about his uncle: "I just don't want to end up like him. Is a tablet not the safest bet?"

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 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Cardiovascular Risk Is Composite, Not a Single Number

●Ten-year cardiovascular risk is estimated from the combination of age, sex, ethnicity, smoking, blood pressure, diabetes, family history, body mass index, and cholesterol — using tools such as QRISK3.
●A moderately raised total cholesterol (e.g. 6.0 mmol/L) with otherwise favourable factors can still yield a low overall risk. The single figure that matters for the primary-prevention decision is the calculated percentage risk, not the cholesterol value alone.

The NICE NG238 Threshold for Primary Prevention

●Offer atorvastatin 20 mg for primary prevention when the 10-year QRISK is 10% or greater.
●Below 10%, a statin is not routinely offered, but may be considered where an informed patient wishes it after discussion, or where the score may underestimate risk (e.g. certain additional risk factors not fully captured).
●At a QRISK of 2.8%, this patient sits well below the treatment threshold; lifestyle modification is first-line.

Smoking Cessation — The Highest-Impact Intervention Here

●For this patient, stopping smoking reduces cardiovascular (and overall) risk more than a statin would at his risk level, and it is the single most valuable thing he can do.
●Offer behavioural support plus pharmacotherapy (nicotine replacement, varenicline where available, or bupropion) and refer to local stop-smoking services; acknowledge previous attempts and build on them.

Lifestyle Management of Modestly Raised Cholesterol

●First-line management at low risk is lifestyle: a diet lower in saturated fat, regular physical activity, maintaining a healthy weight, moderating alcohol, and not smoking.
●Set realistic, specific goals tailored to what the patient already does.

Recognising Familial Hypercholesterolaemia

●Suspect familial hypercholesterolaemia (FH) when the total cholesterol is above 7.5 mmol/L or LDL-C above 4.9 mmol/L, especially with a family history of premature coronary disease or of very high cholesterol, or with tendon xanthomata.
●FH is assessed using criteria such as Simon Broome or Dutch Lipid Clinic Network; suspected FH warrants specialist referral and family cascade testing.
●This patient's cholesterol and family history do not meet FH criteria, but the possibility should be actively considered and excluded, not ignored.

Shared Decision-Making and Informed Choice

●Where a patient below the treatment threshold requests a statin, respect informed choice: discuss the small absolute benefit at low risk, the common and reversible muscle symptoms, the low rate of serious harm, and the monitoring involved.
●A statin may reasonably be prescribed after such a discussion; it may equally reasonably be declined. What matters is that the decision is shared and informed, not paternalistic in either direction.

Managing Health Anxiety Behind a Request

●Requests for tests or treatment are often driven by fear (here, an uncle's heart attack). Addressing the fear directly — with genuine, risk-grounded reassurance — is more effective than granting or refusing the request alone.
●Dismissive reassurance ("you're fine, don't worry") rarely works; reassurance anchored in the patient's actual low risk does.

Reassessing Risk Over Time

●Cardiovascular risk rises with age; a low score at 45 does not mean the question is closed. Arrange periodic reassessment and lipid rechecks as appropriate, so the decision is revisited rather than fixed.

Common Candidate Mistakes in This Case

●Prescribing on the number: starting a statin because the cholesterol is 6, without calculating or heeding the QRISK.
●Flat refusal: declining the statin without explanation or acknowledging that informed choice is permitted, alienating the patient.
●Missing smoking cessation: failing to identify and support the single most effective intervention.
●Ignoring FH: not considering or excluding familial hypercholesterolaemia in a patient presenting with raised cholesterol and a family history.
●Overlooking the fear: treating the encounter as a pure risk calculation and never addressing the health anxiety that prompted the request.

Free MRCGP SCA practice case for GP registrars covering Low Qrisk Score — 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.

← Back to Free SCA Practice Cases