Orris

guideline to treat mi

Reading File
Finding Sources
Searching PubMed

"myocardial infarction"[MeSH Terms] AND "practice guideline"[pt]

Searching the Web

ACC AHA 2024 STEMI NSTEMI guidelines treatment

Finding Sources
Reading Article

PMID: 40014670

Reading Web Page

https://reference.medscape.com/cc1/p10/acc-2025-acc-aha-guid…

Reading File
Finding Sources
Reading File
Finding Sources
Reading File
Finding Sources
Reading File
Finding Sources
Reading File
Reading File
Reading File
Finding Sources
Finding Sources
Finding Sources
Reading File
Reading File
Reading File
Reading File
Loading Image
I now have all the information needed for a comprehensive answer. Here is the complete MI treatment guideline:

Guidelines for the Treatment of Myocardial Infarction

Based on the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for Management of Patients With Acute Coronary Syndromes (PMID 40014670), Harrison's Principles of Internal Medicine (22e), and the Washington Manual of Medical Therapeutics, updated with the full 2025 AHA guideline.

1. Initial Diagnosis and Assessment

ECG and Biomarkers (Time-Critical)
  • 12-lead ECG must be acquired and interpreted within 10 minutes of presentation with suspected ACS symptoms
  • Serial ECGs if initial is non-diagnostic
  • High-sensitivity cardiac troponin (hs-cTn) should be measured immediately, with repeat at 1-2 hours (hs-cTn) or 3-6 hours (standard cTn) if initial result is non-diagnostic
  • ACS is classified as:
    • STEMI - persistent (>20 min) ST elevation + myonecrosis biomarkers = complete coronary occlusion
    • NSTEMI - elevated troponin without ST elevation = subtotal occlusion
    • Unstable Angina (UA) - ischemic symptoms, no troponin rise

2. Immediate General Measures (All ACS)

InterventionDetail
OxygenOnly if SpO₂ < 90% - routine O₂ not recommended
Aspirin162-325 mg loading dose immediately (chewed), then 81 mg/day indefinitely
NitratesSublingual NTG for pain; IV NTG if persistent pain, hypertension, pulmonary edema - avoid if hypotension or RV infarction
MorphineFor severe pain unresponsive to nitrates - use cautiously as it may mask ongoing ischemia and has been associated with worse outcomes
Beta-blockersOral, within 24 hours; reduces ventricular arrhythmias and reinfarction - avoid in cardiogenic shock, acute HF, significant bradycardia/hypotension

3. STEMI: Reperfusion Strategy (Top Priority)

Reperfusion is the cornerstone of STEMI management. The goal is to restore coronary flow as rapidly as possible.
STEMI Reperfusion Decision - PCI vs Fibrinolysis
Fuster and Hurst's The Heart, 15th Edition - Reperfusion decision algorithm

A. Primary PCI (Preferred)

  • First choice when available within 90 minutes of first medical contact (door-to-balloon ≤90 min), or within 120 minutes if transfer is required
  • Superior to fibrinolysis: better vessel patency, lower reinfarction rate, lower intracranial hemorrhage risk, improved survival
  • Indicated for symptom onset <12 hours (can extend to 12-24 hours with ongoing symptoms)
  • In cardiogenic shock (Killip III/IV): primary PCI preferred even if time goals are exceeded
  • Transradial access preferred - reduces bleeding and may improve survival vs. transfemoral
  • Complete revascularization of non-infarct arteries: recommended either during index procedure or within 45 days (EXCEPT in cardiogenic shock - culprit-only PCI preferred per CULPRIT-SHOCK trial)

B. Fibrinolytic Therapy (When PCI Unavailable)

  • Indicated when PCI is not available within 120 minutes
  • Must be given within 30 minutes of presentation (door-to-needle ≤30 min)
  • Most effective within the first 3 hours of symptom onset
  • Eligible time window: within 12 hours of symptom onset with qualifying ECG (ST elevation, new LBBB, true posterior MI)
  • Agents: tenecteplase (TNK), alteplase (tPA), reteplase (rPA), streptokinase
  • After fibrinolysis: transfer to PCI-capable facility; perform angiography 2-24 hours later if reperfusion successful; perform rescue PCI immediately if reperfusion fails (no 50% ST resolution, no pain relief, hemodynamic instability)
Absolute contraindications to fibrinolysis:
  • Prior intracranial hemorrhage
  • Known structural cerebrovascular lesion
  • Ischemic stroke within 3 months
  • Suspected aortic dissection
  • Active bleeding (excluding menses)
  • Significant closed-head trauma within 3 months

4. NSTEMI/Unstable Angina: Invasive vs. Conservative Strategy

All patients receive antithrombotic therapy; the timing of coronary angiography depends on risk:
TimingIndication
Immediate (<2 h)Refractory angina, hemodynamic instability/shock, sustained VT/VF, acute HF/MR
Early invasive (<24 h)High TIMI score (≥3) or GRACE >140, rapid rise in biomarkers, new ST depression
Delayed invasive (24-72 h)Diabetes, renal insufficiency (GFR <60), EF <40%, prior CABG, TIMI ≥2 or GRACE 109-140
Ischemia-driven (conservative)Low-risk (TIMI ≤1, GRACE <109), biomarker-negative, patient preference

5. Antiplatelet Therapy (DAPT)

  • Aspirin 162-325 mg loading, then 81 mg/day indefinitely
  • P2Y12 inhibitor (add to aspirin = Dual Antiplatelet Therapy):
    • Ticagrelor 180 mg load → 90 mg BID (preferred for STEMI/NSTEMI)
    • Prasugrel 60 mg load → 10 mg/day (preferred for PCI; avoid in prior stroke/TIA, age >75, weight <60 kg)
    • Clopidogrel 300-600 mg load → 75 mg/day (use if fibrinolysis, or if ticagrelor/prasugrel contraindicated)
  • Duration: 12 months after ACS (aspirin lifelong; P2Y12 for 12 months)
  • Ticagrelor monotherapy (drop aspirin at 3 months) is an emerging strategy (TICO trial) to reduce bleeding while maintaining efficacy

6. Anticoagulation

  • UFH (unfractionated heparin): Standard with primary PCI; IV bolus + infusion
  • LMWH (enoxaparin): Preferred with fibrinolysis; continue until revascularization or up to 8 days
  • Bivalirudin: Alternative to UFH in PCI settings, particularly with high bleeding risk
  • Fondaparinux: Preferred with conservative NSTEMI strategy (not for primary PCI alone)
  • Stop anticoagulation after successful PCI unless another indication exists

7. Additional Medical Therapies

During Hospitalization

DrugIndication/Timing
Beta-blockersWithin 24 h orally; titrate to HR 50-60 bpm
ACE inhibitorsStart within 24 h if EF <40%, anterior STEMI, HF, hypertension, or diabetes; ARB if ACE intolerant
High-intensity statinStart immediately: atorvastatin 40-80 mg or rosuvastatin 20-40 mg
Aldosterone antagonistIf EF ≤40% + HF or diabetes, without significant renal impairment

Avoid

  • NSAIDs and glucocorticoids (except aspirin): impair infarct healing, increase myocardial rupture risk, reduce flow to ischemic myocardium
  • Routine oxygen if SpO₂ ≥90%

8. Management of Complications

ComplicationManagement
Cardiogenic shockPrimary PCI (culprit-only), inotropes (dobutamine), consider IABP or mechanical support
Acute HF/pulmonary edemaIV diuretics, nitrates, CPAP, intubation if severe
Ventricular fibrillation/VTDefibrillation; amiodarone for refractory VT; beta-blockers
Complete heart block (inferior MI)Temporary pacing; often resolves
Pericarditis (Dressler's)Aspirin, colchicine; avoid NSAIDs/steroids in early post-MI period
Mechanical complications(Free wall rupture, VSD, papillary muscle rupture) - urgent surgical repair

9. Secondary Prevention (Post-MI)

  • Aspirin 81 mg/day indefinitely
  • P2Y12 inhibitor for 12 months (ticagrelor or clopidogrel for stable patients)
  • Beta-blocker (especially if EF <40% or HF)
  • ACE inhibitor/ARB (especially if EF <40%)
  • High-intensity statin (target LDL <55 mg/dL per ESC; <70 mg/dL per ACC/AHA)
  • Eplerenone/spironolactone if EF ≤40% + HF or diabetes
  • Lifestyle: smoking cessation, cardiac rehabilitation, dietary modification, weight management
  • BP target <130/80 mmHg, HbA1c <7% in diabetics

Key Time Targets Summary

GoalTarget
ECG acquisition/interpretation≤10 minutes of arrival
Door-to-balloon (primary PCI)≤90 minutes
First-medical-contact to device (transferred)≤120 minutes
Door-to-needle (fibrinolysis)≤30 minutes
Angiography post-fibrinolysis2-24 hours
Key Reference: 2025 ACC/AHA Guideline for Management of Acute Coronary Syndromes (PMID 40014670) - Rao SV et al., Circulation, 2025. Note: An erratum was published (PMID 41212941).
Additional sources: Harrison's Principles of Internal Medicine 22e, p. 2163 | Washington Manual of Medical Therapeutics, p. 155-157 | Goldman-Cecil Medicine, Ch. 57-58 | Fuster and Hurst's The Heart, 15th Ed.

Create a quick-reference PDF on STEMI reperfusion algorithms

Reading File
Reading File
Running Command

ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or missing"

Running Command

mkdir -p /home/daytona/workspace/stemi-pdf && echo "done"

Writing File

~/stemi-pdf/generate_stemi_pdf.py

"""
STEMI Reperfusion Algorithm - Quick Reference PDF
Uses ReportLab to build a clinical, colour-coded reference card.
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.lib.styles import ParagraphStyle, getSampleStyleSheet
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_RIGHT
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.graphics.shapes import Drawing, Rect, String, Line, Polygon, Arrow
from reportlab.graphics import renderPDF
from reportlab.platypus.flowables import Flowable
import os

OUTPUT = "/home/daytona/workspace/stemi-pdf/STEMI_Reperfusion_QuickRef.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
RED       = colors.HexColor("#C0392B")
DARK_RED  = colors.HexColor("#922B21")
ORANGE    = colors.HexColor("#E67E22")
GREEN     = colors.HexColor("#1A7A4A")
DARK_GREEN= colors.HexColor("#145A32")
BLUE      = colors.HexColor("#1A5276")
LIGHT_BLUE= colors.HexColor("#D6EAF8")
LIGHT_RED = colors.HexColor("#FADBD8")
LIGHT_GREEN=colors.HexColor("#D5F5E3")
LIGHT_ORANGE=colors.HexColor("#FDEBD0")
YELLOW    = colors.HexColor("#F9E79F")
LIGHT_YELLOW=colors.HexColor("#FEF9E7")
GRAY      = colors.HexColor("#566573")
LIGHT_GRAY= colors.HexColor("#F2F3F4")
MID_GRAY  = colors.HexColor("#D5D8DC")
WHITE     = colors.white
BLACK     = colors.black
HEADER_BG = colors.HexColor("#1B2631")
SUBHDR_BG = colors.HexColor("#2E4057")

W, H = A4  # 210 x 297 mm

# ── Custom Flowables ─────────────────────────────────────────────────────────

class ColorBar(Flowable):
    """A solid coloured bar with optional text."""
    def __init__(self, width, height, fill_color, text="", text_color=WHITE,
                 font_size=11, bold=True, radius=3):
        super().__init__()
        self.width = width
        self.height = height
        self.fill_color = fill_color
        self.text = text
        self.text_color = text_color
        self.font_size = font_size
        self.bold = bold
        self.radius = radius

    def draw(self):
        c = self.canv
        c.setFillColor(self.fill_color)
        c.roundRect(0, 0, self.width, self.height, self.radius, fill=1, stroke=0)
        if self.text:
            c.setFillColor(self.text_color)
            font = "Helvetica-Bold" if self.bold else "Helvetica"
            c.setFont(font, self.font_size)
            c.drawCentredString(self.width / 2, self.height / 2 - self.font_size * 0.35,
                                self.text)


class TimingBox(Flowable):
    """A prominent time-target box."""
    def __init__(self, label, value, unit, color, width=None):
        super().__init__()
        self.label = label
        self.value = value
        self.unit = unit
        self.color = color
        self.width = width or 50 * mm
        self.height = 22 * mm

    def draw(self):
        c = self.canv
        w, h = self.width, self.height
        # Outer box
        c.setFillColor(self.color)
        c.roundRect(0, 0, w, h, 4, fill=1, stroke=0)
        # Inner white zone for value
        c.setFillColor(WHITE)
        c.roundRect(2*mm, 2*mm, w - 4*mm, h - 9*mm, 2, fill=1, stroke=0)
        # Value
        c.setFillColor(self.color)
        c.setFont("Helvetica-Bold", 16)
        c.drawCentredString(w / 2, h - 13*mm, self.value)
        # Unit
        c.setFont("Helvetica", 7)
        c.setFillColor(self.color)
        c.drawCentredString(w / 2, h - 16*mm, self.unit)
        # Label at bottom
        c.setFillColor(WHITE)
        c.setFont("Helvetica-Bold", 7)
        c.drawCentredString(w / 2, 1.5*mm, self.label)


# ── Document styles ──────────────────────────────────────────────────────────

def make_styles():
    s = {}
    s["title"] = ParagraphStyle("title",
        fontName="Helvetica-Bold", fontSize=18, textColor=WHITE,
        alignment=TA_CENTER, spaceAfter=2, leading=22)
    s["subtitle"] = ParagraphStyle("subtitle",
        fontName="Helvetica", fontSize=10, textColor=colors.HexColor("#AEB6BF"),
        alignment=TA_CENTER, spaceAfter=2, leading=13)
    s["section"] = ParagraphStyle("section",
        fontName="Helvetica-Bold", fontSize=10, textColor=WHITE,
        alignment=TA_LEFT, leading=13, leftIndent=3)
    s["body"] = ParagraphStyle("body",
        fontName="Helvetica", fontSize=8.5, textColor=BLACK,
        leading=12, spaceAfter=2, leftIndent=4)
    s["body_bold"] = ParagraphStyle("body_bold",
        fontName="Helvetica-Bold", fontSize=8.5, textColor=BLACK,
        leading=12, spaceAfter=2, leftIndent=4)
    s["bullet"] = ParagraphStyle("bullet",
        fontName="Helvetica", fontSize=8, textColor=BLACK,
        leading=11, leftIndent=10, bulletIndent=3, spaceAfter=1)
    s["bullet_bold"] = ParagraphStyle("bullet_bold",
        fontName="Helvetica-Bold", fontSize=8, textColor=BLACK,
        leading=11, leftIndent=10, bulletIndent=3, spaceAfter=1)
    s["small"] = ParagraphStyle("small",
        fontName="Helvetica", fontSize=7, textColor=GRAY,
        leading=9, alignment=TA_CENTER)
    s["small_left"] = ParagraphStyle("small_left",
        fontName="Helvetica", fontSize=7, textColor=GRAY,
        leading=9, alignment=TA_LEFT, leftIndent=4)
    s["warning"] = ParagraphStyle("warning",
        fontName="Helvetica-Bold", fontSize=8, textColor=DARK_RED,
        leading=11, leftIndent=4)
    s["green_bold"] = ParagraphStyle("green_bold",
        fontName="Helvetica-Bold", fontSize=8.5, textColor=DARK_GREEN,
        leading=11, leftIndent=4)
    s["table_header"] = ParagraphStyle("table_header",
        fontName="Helvetica-Bold", fontSize=8, textColor=WHITE,
        alignment=TA_CENTER, leading=10)
    s["table_cell"] = ParagraphStyle("table_cell",
        fontName="Helvetica", fontSize=7.5, textColor=BLACK,
        leading=10, leftIndent=2)
    s["table_cell_bold"] = ParagraphStyle("table_cell_bold",
        fontName="Helvetica-Bold", fontSize=7.5, textColor=BLACK,
        leading=10, leftIndent=2)
    return s


# ── Helper builders ──────────────────────────────────────────────────────────

def section_header(text, color, styles, width=None):
    w = width or (W - 30*mm)
    return [
        ColorBar(w, 7*mm, color, text=text, font_size=9.5),
        Spacer(1, 2*mm),
    ]


def two_col_table(left_content, right_content, col_widths=None, style_extra=None):
    """Wrap two lists of flowables in a side-by-side table."""
    col_widths = col_widths or [88*mm, 88*mm]
    data = [[left_content, right_content]]
    ts = TableStyle([
        ("VALIGN", (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING", (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("TOPPADDING", (0,0), (-1,-1), 0),
        ("BOTTOMPADDING", (0,0), (-1,-1), 0),
    ])
    if style_extra:
        ts.add(*style_extra)
    return Table(data, colWidths=col_widths, style=ts)


def info_table(headers, rows, col_widths, header_color=BLUE):
    """Build a styled clinical table."""
    data = [[Paragraph(h, ParagraphStyle("th", fontName="Helvetica-Bold",
                        fontSize=7.5, textColor=WHITE, alignment=TA_CENTER, leading=10))
             for h in headers]]
    for row in rows:
        data.append([Paragraph(str(cell),
                      ParagraphStyle("td", fontName="Helvetica", fontSize=7.5,
                                     textColor=BLACK, leading=10, leftIndent=2))
                     for cell in row])
    ts = TableStyle([
        ("BACKGROUND", (0,0), (-1,0), header_color),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [WHITE, LIGHT_GRAY]),
        ("GRID", (0,0), (-1,-1), 0.4, MID_GRAY),
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING", (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING", (0,0), (-1,-1), 4),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("ROUNDEDCORNERS", [3]),
    ])
    return Table(data, colWidths=col_widths, style=ts)


def alert_box(text, bg_color, text_color=BLACK, styles=None, width=None):
    w = width or (W - 30*mm)
    p = Paragraph(text, ParagraphStyle("alert",
        fontName="Helvetica-Bold", fontSize=8, textColor=text_color,
        leading=11, leftIndent=6, rightIndent=6))
    t = Table([[p]], colWidths=[w])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg_color),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING", (0,0), (-1,-1), 6),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
        ("ROUNDEDCORNERS", [3]),
    ]))
    return t


# ── Main build ───────────────────────────────────────────────────────────────

def build_pdf():
    doc = SimpleDocTemplate(
        OUTPUT,
        pagesize=A4,
        leftMargin=15*mm, rightMargin=15*mm,
        topMargin=12*mm, bottomMargin=10*mm,
        title="STEMI Reperfusion Algorithm - Quick Reference",
        author="Orris Medical Reference",
        subject="STEMI Management Guidelines 2025"
    )

    styles = make_styles()
    story = []
    full_w = W - 30*mm   # 180 mm usable

    # ═══════════════════════════════════════════════════════════════════
    # HEADER BLOCK
    # ═══════════════════════════════════════════════════════════════════
    header_data = [[
        Paragraph("STEMI REPERFUSION ALGORITHM", styles["title"]),
        Paragraph("Quick Reference Card  |  Based on 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline", styles["subtitle"]),
        Paragraph("For Emergency &amp; Cardiology Use  |  Orris Medical Reference  |  July 2026", styles["subtitle"]),
    ]]
    header_table = Table(header_data, colWidths=[full_w])
    header_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), HEADER_BG),
        ("TOPPADDING", (0,0), (-1,-1), 7),
        ("BOTTOMPADDING", (0,0), (-1,-1), 7),
        ("LEFTPADDING", (0,0), (-1,-1), 8),
        ("RIGHTPADDING", (0,0), (-1,-1), 8),
        ("ROUNDEDCORNERS", [5]),
    ]))
    story.append(header_table)
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # KEY TIME TARGETS
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("KEY TIME TARGETS", RED, styles, full_w)

    box_w = 42*mm
    gap = (full_w - 4 * box_w) / 5
    time_data = [[
        TimingBox("ECG Acquisition", "≤10", "min from arrival", RED, box_w),
        TimingBox("Door-to-Balloon\n(Primary PCI)", "≤90", "min", DARK_RED, box_w),
        TimingBox("1st Contact to Device\n(Transfer PCI)", "≤120", "min", ORANGE, box_w),
        TimingBox("Door-to-Needle\n(Fibrinolysis)", "≤30", "min", GREEN, box_w),
    ]]
    time_table = Table(time_data,
        colWidths=[box_w + gap, box_w + gap, box_w + gap, box_w + gap])
    time_table.setStyle(TableStyle([
        ("LEFTPADDING", (0,0), (-1,-1), gap/2),
        ("RIGHTPADDING", (0,0), (-1,-1), gap/2),
        ("TOPPADDING", (0,0), (-1,-1), 0),
        ("BOTTOMPADDING", (0,0), (-1,-1), 0),
        ("ALIGN", (0,0), (-1,-1), "CENTER"),
    ]))
    story.append(time_table)
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # DIAGNOSIS CRITERIA
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("STEMI DIAGNOSIS CRITERIA", BLUE, styles, full_w)

    diag_left = [
        Paragraph("<b>ST Elevation (New J-point elevation):</b>", styles["body_bold"]),
        Paragraph("• Men &lt;40 yrs: ≥2.5 mm in V2-V3; ≥1 mm in other leads", styles["bullet"]),
        Paragraph("• Men ≥40 yrs: ≥2.0 mm in V2-V3; ≥1 mm in other leads", styles["bullet"]),
        Paragraph("• Women: ≥1.5 mm in V2-V3; ≥1 mm in other leads", styles["bullet"]),
        Paragraph("• Posterior MI: ST depression ≥0.5 mm in V1-V3 + tall R waves", styles["bullet"]),
        Paragraph("• New LBBB with ischaemic symptoms = treat as STEMI", styles["bullet"]),
    ]
    diag_right = [
        Paragraph("<b>Immediate Actions:</b>", styles["body_bold"]),
        Paragraph("• 12-lead ECG within <b>10 min</b> of presentation", styles["bullet"]),
        Paragraph("• Serial ECGs if initial non-diagnostic", styles["bullet"]),
        Paragraph("• hs-Troponin: baseline + 1-2 h repeat", styles["bullet"]),
        Paragraph("• IV access, O<sub>2</sub> only if SpO<sub>2</sub> &lt;90%", styles["bullet"]),
        Paragraph("• Aspirin 162-325 mg (chewed) immediately", styles["bullet"]),
        Paragraph("• Activate cath lab / transfer pathway NOW", styles["bullet"]),
    ]
    story.append(two_col_table(diag_left, diag_right, [90*mm, 90*mm]))
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # REPERFUSION DECISION
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("REPERFUSION STRATEGY DECISION", SUBHDR_BG, styles, full_w)

    # PCI column
    pci_items = [
        ColorBar(88*mm, 6*mm, DARK_RED, "PRIMARY PCI  (Preferred Strategy)", font_size=8.5),
        Spacer(1, 2*mm),
        Paragraph("<b>Indications / Favours PCI:</b>", styles["body_bold"]),
        Paragraph("• PCI available within <b>90 min</b> of 1st medical contact", styles["bullet"]),
        Paragraph("• Transfer possible with device time <b>≤120 min</b>", styles["bullet"]),
        Paragraph("• Cardiogenic shock / Killip III-IV", styles["bullet"]),
        Paragraph("• Contraindication to fibrinolysis", styles["bullet"]),
        Paragraph("• Symptoms &gt;3 h (clot less lysable)", styles["bullet"]),
        Paragraph("• Diagnosis uncertain", styles["bullet"]),
        Paragraph("• Prior CABG or PCI", styles["bullet"]),
        Paragraph("• High bleeding risk with lytics", styles["bullet"]),
        Spacer(1, 2*mm),
        Paragraph("<b>Technical Points:</b>", styles["body_bold"]),
        Paragraph("• Stenting superior to balloon angioplasty alone", styles["bullet"]),
        Paragraph("• <b>Transradial access preferred</b> (↓ bleeding, possible mortality benefit)", styles["bullet"]),
        Paragraph("• Complete revascularisation of non-culprit arteries (index or within 45 days)", styles["bullet"]),
        Paragraph("• <b>Cardiogenic shock:</b> culprit-only PCI (CULPRIT-SHOCK trial)", styles["bullet"]),
        Paragraph("• No facilitated PCI (lytics + GPIIb/IIIa pre-PCI — increases bleeding)", styles["bullet"]),
    ]

    # Fibrinolysis column
    fib_items = [
        ColorBar(88*mm, 6*mm, DARK_GREEN, "FIBRINOLYSIS  (When PCI Unavailable)", font_size=8.5),
        Spacer(1, 2*mm),
        Paragraph("<b>Indications / Favours Fibrinolysis:</b>", styles["body_bold"]),
        Paragraph("• PCI delay &gt;120 min (1st contact to device)", styles["bullet"]),
        Paragraph("• Very early presentation (&lt;2-3 h) at non-PCI hospital", styles["bullet"]),
        Paragraph("• Low bleeding risk", styles["bullet"]),
        Spacer(1, 1*mm),
        Paragraph("<b>Agents (IV):</b>", styles["body_bold"]),
        Paragraph("• Tenecteplase (TNK) — weight-based bolus <b>[preferred]</b>", styles["bullet"]),
        Paragraph("• Alteplase (tPA) — 15 mg IV bolus → 0.75 mg/kg over 30 min → 0.5 mg/kg over 60 min", styles["bullet"]),
        Paragraph("• Reteplase (rPA) — 10 U IV x 2 (30 min apart)", styles["bullet"]),
        Paragraph("• Streptokinase — 1.5 MU over 60 min (no fibrin specificity)", styles["bullet"]),
        Spacer(1, 2*mm),
        Paragraph("<b>Post-Fibrinolysis:</b>", styles["body_bold"]),
        Paragraph("• Transfer ALL patients to PCI-capable centre", styles["bullet"]),
        Paragraph("• Angiography at <b>2-24 h</b> if successful reperfusion", styles["bullet"]),
        Paragraph("• <b>Rescue PCI immediately</b> if reperfusion fails:", styles["bullet"]),
        Paragraph("  - No ≥50% ST resolution at 60-90 min", styles["small_left"]),
        Paragraph("  - Persistent pain / haemodynamic instability", styles["small_left"]),
    ]

    story.append(two_col_table(pci_items, fib_items, [90*mm, 90*mm]))
    story.append(Spacer(1, 2*mm))

    # Fibrinolysis contraindications
    abs_ci = [
        "Prior intracranial haemorrhage (any time)",
        "Known intracranial neoplasm / AVM",
        "Ischaemic stroke within 3 months",
        "Suspected aortic dissection",
        "Active internal bleeding (not menses)",
        "Significant closed-head trauma/facial fracture &lt;3 months",
    ]
    rel_ci = [
        "Uncontrolled HTN (SBP &gt;180 or DBP &gt;110 mmHg)",
        "Ischaemic stroke &gt;3 months ago",
        "Traumatic or prolonged CPR (&gt;10 min)",
        "Major surgery within 3 weeks",
        "Internal bleeding within 2-4 weeks",
        "Pregnancy",
        "Active peptic ulcer",
        "Current anticoagulant use (INR &gt;2-3)",
    ]

    ci_left = [
        ColorBar(88*mm, 5.5*mm, RED, "ABSOLUTE CONTRAINDICATIONS to Fibrinolysis", font_size=8),
        Spacer(1, 1.5*mm),
    ] + [Paragraph(f"<b>&#10006;</b>  {x}", styles["bullet"]) for x in abs_ci]

    ci_right = [
        ColorBar(88*mm, 5.5*mm, ORANGE, "RELATIVE CONTRAINDICATIONS to Fibrinolysis", font_size=8),
        Spacer(1, 1.5*mm),
    ] + [Paragraph(f"&#9651;  {x}", styles["bullet"]) for x in rel_ci]

    story.append(two_col_table(ci_left, ci_right, [90*mm, 90*mm]))
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # ANTITHROMBOTIC THERAPY
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("ANTITHROMBOTIC THERAPY", BLUE, styles, full_w)

    antip_headers = ["Agent", "Loading Dose", "Maintenance", "Notes"]
    antip_rows = [
        ["Aspirin", "162-325 mg PO (chewed)", "81 mg/day indefinitely", "Give immediately; first line always"],
        ["Ticagrelor", "180 mg PO", "90 mg BID x 12 months", "Preferred P2Y12 for PCI/ACS; reversible"],
        ["Prasugrel", "60 mg PO", "10 mg/day x 12 months", "Preferred with PCI; avoid if prior TIA/stroke, age >75, wt <60 kg"],
        ["Clopidogrel", "300-600 mg PO", "75 mg/day x 12 months", "Use with fibrinolysis or if ticagrelor/prasugrel contraindicated"],
    ]
    story.append(info_table(antip_headers, antip_rows,
        [28*mm, 42*mm, 48*mm, 62*mm], BLUE))
    story.append(Spacer(1, 2*mm))

    anticoag_headers = ["Anticoagulant", "Dose / Route", "Indication", "Notes"]
    anticoag_rows = [
        ["UFH", "60 U/kg IV bolus (max 4000 U) + 12 U/kg/h infusion", "Primary PCI or fibrinolysis", "Adjust to aPTT 50-70 s; stop after PCI unless indicated"],
        ["Enoxaparin (LMWH)", "1 mg/kg SC q12h (or 0.75 mg/kg if age >75)", "Fibrinolysis / NSTEMI", "Continue up to 8 days or until revascularisation; preferred over UFH with lytics"],
        ["Bivalirudin", "0.75 mg/kg IV bolus + 1.75 mg/kg/h during PCI", "Primary PCI", "Alternative to UFH; fewer bleeding complications"],
        ["Fondaparinux", "2.5 mg SC daily", "NSTEMI conservative strategy", "Do NOT use alone for primary PCI (risk catheter thrombus)"],
    ]
    story.append(info_table(anticoag_headers, anticoag_rows,
        [26*mm, 50*mm, 44*mm, 60*mm], BLUE))
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # ADDITIONAL THERAPIES & COMPLICATION MANAGEMENT
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("ADDITIONAL ACUTE THERAPIES", GRAY, styles, full_w)

    med_left = [
        Paragraph("<b>Beta-Blockers</b>", styles["body_bold"]),
        Paragraph("• Oral, within 24 h; target HR 50-60 bpm", styles["bullet"]),
        Paragraph("• Metoprolol 25-50 mg PO q6-12 h (titrate up)", styles["bullet"]),
        Paragraph("• <b>Avoid if:</b> cardiogenic shock, acute HF, significant bradycardia, PR &gt;240 ms, 2nd/3rd degree AVB", styles["bullet"]),
        Spacer(1, 2*mm),
        Paragraph("<b>ACE Inhibitors / ARBs</b>", styles["body_bold"]),
        Paragraph("• Start within 24 h if: EF &lt;40%, anterior STEMI, HF, hypertension, or diabetes", styles["bullet"]),
        Paragraph("• Ramipril 2.5 mg → titrate to 10 mg/day; Lisinopril 5 mg/day", styles["bullet"]),
        Paragraph("• ARB (e.g. valsartan) if ACE inhibitor intolerant", styles["bullet"]),
        Spacer(1, 2*mm),
        Paragraph("<b>Statins (High-Intensity)</b>", styles["body_bold"]),
        Paragraph("• Start immediately: Atorvastatin 40-80 mg OR Rosuvastatin 20-40 mg", styles["bullet"]),
        Paragraph("• Target LDL &lt;55 mg/dL (ESC) / &lt;70 mg/dL (ACC/AHA)", styles["bullet"]),
    ]

    med_right = [
        Paragraph("<b>Nitrates</b>", styles["body_bold"]),
        Paragraph("• Sublingual GTN for chest pain relief", styles["bullet"]),
        Paragraph("• IV nitroglycerine if persistent pain, HTN, pulmonary oedema", styles["bullet"]),
        Paragraph("• <b>Avoid if:</b> SBP &lt;90 mmHg, HR &lt;50 or &gt;100, RV infarction, phosphodiesterase inhibitor use", styles["bullet"]),
        Spacer(1, 2*mm),
        Paragraph("<b>Aldosterone Antagonist</b>", styles["body_bold"]),
        Paragraph("• Eplerenone 25 mg/day → 50 mg/day (preferred); or spironolactone", styles["bullet"]),
        Paragraph("• Indication: EF ≤40% + HF symptoms OR diabetes", styles["bullet"]),
        Paragraph("• Avoid if: K &gt;5.0 mEq/L, creatinine &gt;2.5 (men) / &gt;2.0 (women) mg/dL", styles["bullet"]),
        Spacer(1, 2*mm),
        Paragraph("<b>Oxygen</b>", styles["body_bold"]),
        Paragraph("• Only if SpO<sub>2</sub> &lt;90% — routine O<sub>2</sub> is <b>NOT</b> recommended", styles["bullet"]),
        Spacer(1, 1*mm),
        Paragraph("<b>Avoid:</b>", styles["warning"]),
        Paragraph("• NSAIDs / corticosteroids (except aspirin): impair healing, increase rupture risk", styles["bullet"]),
        Paragraph("• Morphine: use cautiously — may mask ischaemia, associated with worse outcomes", styles["bullet"]),
    ]

    story.append(two_col_table(med_left, med_right, [90*mm, 90*mm]))
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # COMPLICATIONS
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("COMPLICATION MANAGEMENT", DARK_RED, styles, full_w)

    comp_headers = ["Complication", "Clinical Features", "Management"]
    comp_rows = [
        ["Cardiogenic Shock\n(Killip IV)", "SBP <90, cool peripheries,\nconfusion, oliguria",
         "Culprit-only primary PCI; dobutamine/dopamine; consider IABP or Impella; avoid routine non-culprit PCI"],
        ["Acute Pulm. Oedema\n(Killip III)", "Dyspnoea, crackles, SpO2 ↓,\nfoamy sputum",
         "Upright positioning, IV furosemide, IV nitrates (if SBP >100), CPAP/NIV; intubate if severe"],
        ["VF / Pulseless VT", "Cardiac arrest", "Immediate defibrillation; CPR; amiodarone 300 mg IV after 3rd shock"],
        ["Sustained VT\n(haemodynamically unstable)", "Hypotension, syncope", "Synchronised DC cardioversion; amiodarone 150 mg IV over 10 min"],
        ["Complete Heart Block\n(inferior MI)", "HR <40, haemodynamic compromise", "Atropine 0.5-1 mg IV; transcutaneous/transvenous pacing; usually reversible"],
        ["Acute MR\n(papillary muscle rupture)", "Sudden pulm. oedema, new murmur", "Urgent surgical repair; bridge with IABP, vasodilators if haemodynamically stable"],
        ["VSD\n(septal rupture)", "New harsh pansystolic murmur,\nRHF + LHF", "Urgent surgery; IABP as bridge; high mortality if surgery delayed"],
        ["Free Wall Rupture", "Sudden haemodynamic collapse,\ntamponade", "Emergency pericardiocentesis; immediate cardiac surgery"],
        ["Pericarditis\n(early / Dressler)", "Pleuritic chest pain, friction rub,\nST changes (saddle-shaped)", "Aspirin (high dose) + colchicine; avoid NSAIDs/steroids early post-MI"],
    ]
    story.append(info_table(comp_headers, comp_rows,
        [30*mm, 44*mm, 106*mm], DARK_RED))
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # SECONDARY PREVENTION
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("SECONDARY PREVENTION (DISCHARGE)", DARK_GREEN, styles, full_w)

    sec_left = [
        Paragraph("<b>Medications at Discharge:</b>", styles["body_bold"]),
        Paragraph("&#10003;  Aspirin 81 mg/day — <b>indefinitely</b>", styles["bullet"]),
        Paragraph("&#10003;  P2Y12 inhibitor (ticagrelor or clopidogrel) — <b>12 months</b>", styles["bullet"]),
        Paragraph("&#10003;  Beta-blocker — <b>minimum 1-3 years post-MI</b> (lifelong if EF &lt;40%)", styles["bullet"]),
        Paragraph("&#10003;  High-intensity statin — <b>indefinitely</b>", styles["bullet"]),
        Paragraph("&#10003;  ACE inhibitor/ARB — indefinitely if EF &lt;40%, HF, DM, or HTN", styles["bullet"]),
        Paragraph("&#10003;  Aldosterone antagonist — if EF ≤40% + HF or DM", styles["bullet"]),
    ]
    sec_right = [
        Paragraph("<b>Lifestyle &amp; Targets:</b>", styles["body_bold"]),
        Paragraph("• <b>Smoking cessation</b> — most impactful secondary prevention", styles["bullet"]),
        Paragraph("• Cardiac rehabilitation — strongly recommended", styles["bullet"]),
        Paragraph("• BP target: &lt;130/80 mmHg", styles["bullet"]),
        Paragraph("• LDL target: &lt;55 mg/dL (ESC) / &lt;70 mg/dL (ACC/AHA)", styles["bullet"]),
        Paragraph("• HbA1c: &lt;7% in diabetics", styles["bullet"]),
        Paragraph("• BMI: target 18.5-24.9 kg/m<sup>2</sup>; Mediterranean diet", styles["bullet"]),
        Paragraph("• Physical activity: 150 min moderate aerobic/week after clearance", styles["bullet"]),
    ]
    story.append(two_col_table(sec_left, sec_right, [90*mm, 90*mm]))
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # NSTEMI TIMING SUMMARY
    # ═══════════════════════════════════════════════════════════════════
    story += section_header("NSTEMI / UNSTABLE ANGINA: INVASIVE STRATEGY TIMING", BLUE, styles, full_w)

    nstemi_headers = ["Timing", "Criteria", "Examples"]
    nstemi_rows = [
        ["Immediate\n(<2 h)", "Any HIGH-RISK feature", "Refractory ischaemia, haemodynamic instability, cardiogenic shock, sustained VT/VF, acute HF/MR"],
        ["Early Invasive\n(<24 h)", "High-risk without immediate criteria", "TIMI ≥3 or GRACE >140; rapid biomarker rise; new ST depression; prior PCI <6 months"],
        ["Delayed Invasive\n(24-72 h)", "Intermediate risk", "Diabetes; renal insufficiency (GFR <60); EF <40%; early post-infarct angina; GRACE 109-140; prior CABG"],
        ["Ischemia-Driven\n(Conservative)", "Low risk", "TIMI ≤1 or GRACE <109; biomarker-negative; low-risk female patients; patient/clinician preference without high-risk features"],
    ]
    story.append(info_table(nstemi_headers, nstemi_rows,
        [30*mm, 38*mm, 112*mm], BLUE))
    story.append(Spacer(1, 3*mm))

    # ═══════════════════════════════════════════════════════════════════
    # FOOTER
    # ═══════════════════════════════════════════════════════════════════
    story.append(HRFlowable(width=full_w, thickness=0.5, color=MID_GRAY, spaceAfter=2*mm))

    footer_data = [[
        Paragraph(
            "<b>Source:</b> 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for Management of Patients With Acute Coronary Syndromes "
            "(Rao SV et al., Circulation 2025; DOI: 10.1161/CIR.0000000000001309 | PMID: 40014670). "
            "Also: Harrison's Principles of Internal Medicine 22e; Goldman-Cecil Medicine; Washington Manual of Medical Therapeutics; "
            "Fuster and Hurst's The Heart 15e.",
            styles["small"]
        ),
        Paragraph(
            "<b>Disclaimer:</b> For educational use only. Always apply clinical judgement and consult local protocols.",
            styles["small"]
        ),
    ]]
    footer_table = Table(footer_data, colWidths=[full_w])
    footer_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), LIGHT_GRAY),
        ("TOPPADDING", (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING", (0,0), (-1,-1), 6),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
        ("ROUNDEDCORNERS", [3]),
    ]))
    story.append(footer_table)

    # ── Build ──
    doc.build(story)
    print(f"PDF saved to: {OUTPUT}")


if __name__ == "__main__":
    build_pdf()
Running Command

cd /home/daytona/workspace/stemi-pdf && python generate_stemi_pdf.py 2>&1

Editing File

~/stemi-pdf/generate_stemi_pdf.py

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/stemi-pdf/generate_stemi_pdf.py'
Running Command

cd /home/daytona/workspace/stemi-pdf && python generate_stemi_pdf.py 2>&1

Running Command

ls -lh /home/daytona/workspace/stemi-pdf/STEMI_Reperfusion_QuickRef.pdf

Running Command

cd /home/daytona/workspace/stemi-pdf && python -c " from pypdf import PdfReader …

Running Command

cd /home/daytona/workspace/stemi-pdf && python -c " from pypdf import PdfReader …

All sections are rendering correctly across 3 pages. The PDF is complete and well-structured. Here it is:
Your STEMI Quick Reference PDF is ready:

STEMI Reperfusion QuickRef

PDF Document · PDF

What's inside (3 pages, A4):
SectionContent
Key Time TargetsColour-coded boxes: ECG ≤10 min, door-to-balloon ≤90 min, transfer ≤120 min, lytic door-to-needle ≤30 min
STEMI Diagnosis CriteriaST elevation thresholds by sex/age; posterior MI; new LBBB
Reperfusion DecisionPrimary PCI indications vs. fibrinolysis indications side-by-side; absolute and relative contraindications to fibrinolysis
Antithrombotic TherapyAntiplatelet table (aspirin, ticagrelor, prasugrel, clopidogrel with doses); anticoagulant table (UFH, enoxaparin, bivalirudin, fondaparinux)
Additional TherapiesBeta-blockers, ACE inhibitors, statins, nitrates, aldosterone antagonists; avoid list (NSAIDs, routine O2, morphine caution)
Complications9-row table covering cardiogenic shock, pulmonary oedema, VF/VT, CHB, acute MR, VSD, free wall rupture, pericarditis
Secondary PreventionDischarge medications checklist + lifestyle targets
NSTEMI TimingImmediate/early/delayed/conservative invasive strategy criteria
Based on the 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline (PMID 40014670) with supporting content from Harrison's 22e, Goldman-Cecil Medicine, and Washington Manual of Medical Therapeutics.
This is a shared conversation. Sign in to Orris to start your own chat.