Cardiovascular Prevention and Rehabilitation — Written Clinical Reasoning

Model answer — Part A: the 48-year-old with LDL 5.2 and a family history

Frame the problem first. This is a primary-prevention consultation with two independent risk amplifiers: a markedly elevated LDL and a first-degree relative with premature coronary disease. The task is to calculate absolute risk, exclude secondary and inherited dyslipidaemia, and treat the total risk — not just the cholesterol [1].

Assessment. Calculate 5-year absolute CVD risk with the AusCVDRisk calculator using non-fasting lipids, blood pressure, smoking, diabetes status, renal function and albuminuria; his untreated LDL of 5.2 mmol/L with premature paternal MI pushes him toward the high-risk category and also triggers formal familial hypercholesterolaemia assessment [1]. Screen for secondary causes: TSH, HbA1c, renal and liver function, urinary protein, alcohol and medications. Examine for tendon xanthomata and corneal arcus, and apply the Dutch Lipid Clinic Network criteria — premature paternal MI scores, and LDL above 5.0 mmol/L scores further points; score 3–5 is possible FH and warrants family screening regardless [2].

Management. Lifestyle for everyone: Mediterranean dietary pattern (PREDIMED-grade evidence), 150 minutes of weekly moderate exercise, weight and alcohol review, and structured smoking avoidance advice [1]. Given his risk profile, commence a statin — moderate-to-high intensity depending on the calculated category — aiming for at least a 50% LDL reduction in line with the CTT dose-response, rechecking lipids and liver enzymes at 6–8 weeks and titrating rather than abandoning [3]. Address his blood pressure against his risk category, not an isolated threshold [1].

Close the loop. If FH is confirmed or probable, explain the inheritance, arrange cascade screening of first-degree relatives (including his siblings and children at the appropriate age), and plan long-term follow-up — the EAS consensus identifies cascade screening as the most cost-effective case-finding in preventive cardiology [2].