DYSLIPIDEMIA - High-Yield Presentation Summary

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pres.title = "Dyslipidemia – ACC/AHA 2026 Guideline";
pres.author = "Medical Presentation";

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// ─── HELPERS ─────────────────────────────────────────────────────────────────
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// ─── SLIDE 1: TITLE ──────────────────────────────────────────────────────────
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  s.addText("ACC / AHA 2026 Clinical Practice Guideline", {
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  s.addText("Published: March 13, 2026  |  JACC & Circulation  |  Replaces 2018 Blood Cholesterol Guideline", {
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// ─── SLIDE 2: WHY A NEW GUIDELINE? ───────────────────────────────────────────
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  titleBar(s, "Why a New Guideline? — Key Changes from 2018", "ACC/AHA 2026 | Full replacement of the 2018 Blood Cholesterol Guideline");

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    { icon: "►", color: C.red,    bold: "LDL-C targets restored:", text: " 2018 dropped numeric goals; 2026 reinstates specific LDL-C & non-HDL-C targets per risk tier." },
    { icon: "►", color: C.teal,   bold: "Broader scope:", text: " Renamed from 'Blood Cholesterol' to 'Dyslipidemia' — now includes TG-rich remnants, Lp(a), and HDL disorders." },
    { icon: "►", color: C.navy,   bold: "PREVENT replaces PCE:", text: " Pooled Cohort Equations overestimated risk by 40–50%. New PREVENT tool provides accurate modern estimates." },
    { icon: "►", color: C.green,  bold: "Universal Lp(a) testing:", text: " Class I: measure at least once in ALL adults. Lp(a) ≥125 nmol/L = independent risk enhancer." },
    { icon: "►", color: C.orange, bold: "Five new FDA-approved therapies:", text: " Inclisiran, bempedoic acid, evinacumab, volanesorsen, and pemafibrate formally incorporated." },
    { icon: "►", color: C.teal,   bold: "Pediatric screening:", text: " Universal lipid screen for all children at age 9–11 years." },
    { icon: "►", color: C.navy,   bold: "CAC expanded:", text: " CAC >0 now triggers LLT initiation (Class I); incidental CT CAC findings should be acted upon." },
    { icon: "►", color: C.red,    bold: "ApoB selective use:", text: " Class IIa to guide intensification in ASCVD, T2DM, elevated TG, or discordant LDL-C/ApoB." },
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// ─── SLIDE 3: SECTION DIVIDER – PATHOPHYSIOLOGY ──────────────────────────────
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  sectionDivider(s, 1, "Pathophysiology", "How lipid disorders drive atherosclerotic cardiovascular disease");
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// ─── SLIDE 4: LIPOPROTEIN METABOLISM & ATHEROGENESIS ─────────────────────────
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  titleBar(s, "Lipoprotein Metabolism & Atherogenesis", "Understanding the pathophysiological basis of dyslipidemia");

  // Left column: lipoprotein table
  const lipoproteins = [
    { lp: "Chylomicrons", origin: "Intestine", carries: "Dietary TG", fate: "LPL → remnants → liver" },
    { lp: "VLDL", origin: "Liver", carries: "Endogenous TG", fate: "LPL → IDL → LDL" },
    { lp: "IDL", origin: "VLDL catabolism", carries: "Chol + TG", fate: "Liver / → LDL" },
    { lp: "LDL", origin: "IDL catabolism", carries: "Cholesterol", fate: "LDL-R uptake (liver & tissues)" },
    { lp: "HDL", origin: "Liver/intestine", carries: "Reverse chol", fate: "Liver → bile excretion" },
    { lp: "Lp(a)", origin: "Liver (genetic)", carries: "Chol + apo(a)", fate: "Pro-atherogenic + pro-thrombotic" },
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    { step: "2", text: "LDL becomes oxidized (ox-LDL) → endothelial activation" },
    { step: "3", text: "Monocytes recruited → macrophages → engulf ox-LDL → Foam cells" },
    { step: "4", text: "Fatty streak → fibrous plaque (SMC migration, collagen deposition)" },
    { step: "5", text: "Plaque instability → rupture → thrombus → ACS / Stroke / PAD" },
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  s.addText("KEY: Each 1 mmol/L (39 mg/dL) ↓ LDL-C = ~22% ↓ major CV events (Cholesterol Treatment Trialists meta-analysis) — causal, linear, lifelong relationship", {
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  footer(s, 3);
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// ─── SLIDE 5: SECTION – CLASSIFICATION ───────────────────────────────────────
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  sectionDivider(s, 2, "Classification & Definitions", "Fredrickson/WHO phenotypic system + modern clinical classification");
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// ─── SLIDE 6: FREDRICKSON CLASSIFICATION ─────────────────────────────────────
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  titleBar(s, "Fredrickson / WHO Classification of Dyslipidemia", "Phenotypic classification by elevated lipoprotein class");

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    { type:"I",   disorder:"Familial Hyperchylomicronemia",    lp:"Chylomicrons", ldl:"N",   tg:"↑↑↑", chd:"None",  feat:"LPL/apoCII deficiency; pancreatitis; no drug effective; low-fat diet",    color:"E8F8F5" },
    { type:"IIA", disorder:"Familial Hypercholesterolemia",     lp:"LDL",          ldl:"↑↑↑", tg:"N",   chd:"↑↑↑",  feat:"LDL receptor defect; tendon xanthomas; early MI; FH diagnosis",           color:"FDEBD0" },
    { type:"IIB", disorder:"Familial Combined Hyperlipidemia",  lp:"LDL + VLDL",   ldl:"↑",   tg:"↑",   chd:"↑↑",   feat:"Most common familial type; ↑ hepatic VLDL production",                   color:"E8F8F5" },
    { type:"III", disorder:"Dysbetalipoproteinemia",            lp:"IDL (remnants)",ldl:"↑",  tg:"↑",   chd:"↑↑",   feat:"ApoE2/E2 mutation; palmar xanthomas; vascular disease by mid-life",       color:"FDEBD0" },
    { type:"IV",  disorder:"Familial Hypertriglyceridemia",     lp:"VLDL",         ldl:"N/↑", tg:"↑↑",  chd:"↑",    feat:"Common; obesity/DM; ↑ VLDL production and/or ↓ clearance",               color:"E8F8F5" },
    { type:"V",   disorder:"Mixed Hypertriglyceridemia",        lp:"VLDL + Chylos",ldl:"N/↓", tg:"↑↑↑", chd:"↑",   feat:"Genetic + secondary; pancreatitis risk; obesity/DM; severe HTG",         color:"FDEBD0" },
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  s.addText("Modern classification also distinguishes: Primary (genetic) vs Secondary (acquired) vs Mixed | AHA 2026: LDL-C ≥190 mg/dL → suspect FH and screen family", {
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  footer(s, 4);
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// ─── SLIDE 7: SECTION – RISK ASSESSMENT ──────────────────────────────────────
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  sectionDivider(s, 3, "Risk Assessment", "PREVENT Equations · Lp(a) · CAC · Risk Enhancers");
}

// ─── SLIDE 8: PREVENT RISK TOOL & CATEGORIES ─────────────────────────────────
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  titleBar(s, "PREVENT Equations & Risk Stratification (AHA 2026 Class I)", "Replaces the 2013 Pooled Cohort Equations (PCE) — reduces overestimation by 40–50%");

  // PREVENT box
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  s.addText("PREVENT-ASCVD Equations", { x: 0.35, y: 1.12, w: 4.4, h: 0.38, fontSize: 13, bold: true, color: C.gold, valign: "middle", margin: 6 });
  s.addText([
    { text: "• Age range: 30–79 years\n", options: {} },
    { text: "• Estimates 10-year & 30-year ASCVD risk\n", options: {} },
    { text: "• Includes CKM variables (eGFR, UACR, BMI, HbA1c)\n", options: {} },
    { text: "• Non-fasting lipids acceptable", options: {} },
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  // Risk categories
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    { label:"LOW",          val:"<3%",   color:C.green,  action:"Lifestyle counseling; consider statin if LDL 160–189 mg/dL or 30-yr risk ≥10%" },
    { label:"BORDERLINE",   val:"3–<5%", color:C.gold,   action:"Consider moderate-intensity statin; aim 30–49% LDL-C reduction" },
    { label:"INTERMEDIATE", val:"5–<10%",color:C.orange, action:"≥ Moderate statin; target LDL-C <100 mg/dL; use risk enhancers / CAC to decide" },
    { label:"HIGH",         val:"≥10%",  color:C.red,    action:"High-intensity statin; target LDL-C <70 mg/dL + ≥50% reduction" },
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  s.addText("Risk-Enhancing Factors (tip the decision)", { x: 0.35, y: 2.27, w: 4.4, h: 0.32, fontSize: 10, bold: true, color: C.white, valign: "middle", margin: 4 });
  const enhancers = [
    "Family hx premature ASCVD (<55M / <65F)",
    "LDL-C ≥160 mg/dL or non-HDL-C ≥190 mg/dL (persistent)",
    "Lp(a) ≥125 nmol/L (≥50 mg/dL)",
    "hsCRP ≥2 mg/L (on 2 occasions, no identifiable cause)",
    "ABI <0.9 (subclinical PAD)",
    "Metabolic syndrome (3+ criteria)",
    "Chronic kidney disease (eGFR 15–59)",
    "Chronic inflammatory conditions (RA, psoriasis, HIV)",
    "Premature menopause (<40 yrs) / history of pre-eclampsia",
  ];
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  // Lp(a) & CAC bottom strip
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  s.addText("Lp(a) — Class I: Measure ONCE in ALL adults | ≥125 nmol/L = risk enhancer | ≥250 nmol/L = ≥2× risk | Fasting not required", {
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  s.addText("CAC — Class I: CAC >0 → initiate LLT (esp. ≥100 AU or ≥75th %ile) | CAC=0 → defer, repeat in 3–7 yrs | Incidental CT finding → act", {
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  footer(s, 5);
}

// ─── SLIDE 9: SECTION – CLINICAL PRESENTATION & LABS ─────────────────────────
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  sectionDivider(s, 4, "Clinical Presentation & Lab Investigations", "Signs, symptoms, screening, and biomarker testing");
}

// ─── SLIDE 10: CLINICAL FEATURES & INVESTIGATIONS ────────────────────────────
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  titleBar(s, "Clinical Presentation & Laboratory Investigations", "Most patients are ASYMPTOMATIC — detected by screening");

  // Left: Physical signs
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  const signs = [
    { sign: "Tendinous xanthomas", assoc: "FH (Type IIA) — Achilles, extensor tendons", color: C.red },
    { sign: "Eruptive xanthomas", assoc: "Hypertriglyceridemia >500–1000 mg/dL (Types I, IV, V)", color: C.orange },
    { sign: "Tuberous xanthomas", assoc: "Type IIA/III — over elbows, knees", color: C.orange },
    { sign: "Xanthelasma", assoc: "Periorbital yellow plaques — not specific", color: C.gold },
    { sign: "Corneal arcus <45 yrs", assoc: "Suspect FH in young patients", color: C.teal },
    { sign: "Lipemia retinalis", assoc: "TG >2000 mg/dL — creamy retinal vessels", color: C.navy },
    { sign: "Hepatosplenomegaly", assoc: "Chylomicronemia syndrome (Type I/V)", color: C.gray },
  ];
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    const y = 1.42 + i * 0.36;
    s.addShape(pres.ShapeType.roundRect, { x: 0.35, y: y + 0.04, w: 1.55, h: 0.26, fill: { color: sg.color }, rectRadius: 0.05 });
    s.addText(sg.sign, { x: 0.35, y: y + 0.04, w: 1.55, h: 0.26, fontSize: 7.5, bold: true, color: C.white, align: "center", valign: "middle", margin: 2 });
    s.addText(sg.assoc, { x: 1.95, y: y + 0.02, w: 2.8, h: 0.3, fontSize: 8, color: C.gray, valign: "middle", margin: 2 });
  });

  // Complications
  s.addShape(pres.ShapeType.roundRect, { x: 0.28, y: 4.08, w: 4.55, h: 0.85, fill: { color: C.red }, rectRadius: 0.1 });
  s.addText("COMPLICATIONS:", { x: 0.38, y: 4.1, w: 4.3, h: 0.22, fontSize: 9, bold: true, color: C.white, margin: 2 });
  s.addText("Premature CAD/MI  •  Ischemic Stroke  •  PAD / Claudication\nAcute Pancreatitis (TG >500–1000 mg/dL)  •  HF (IHD-related)", {
    x: 0.38, y: 4.3, w: 4.3, h: 0.57, fontSize: 8.5, color: C.white, margin: 2,
  });

  // Right: Lab investigations
  s.addShape(pres.ShapeType.roundRect, { x: 5.0, y: 1.08, w: 4.72, h: 3.85, fill: { color: C.white }, line: { color: C.teal, width: 1 }, rectRadius: 0.1 });
  s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.08, w: 4.72, h: 0.3, fill: { color: C.teal } });
  s.addText("Laboratory Investigations", { x: 5.05, y: 1.08, w: 4.6, h: 0.3, fontSize: 10, bold: true, color: C.white, valign: "middle", margin: 4 });

  const labs = [
    { test:"Standard Lipid Panel", detail:"TC, LDL-C, HDL-C, TG, non-HDL-C\nFasting not required unless known hypertriglyceridemia\nScreen adults from age 19; children at age 9–11 (universal)" },
    { test:"LDL-C Calculation", detail:"Martin/Hopkins or Sampson/NIH (AHA 2026 Class I)\nPreferred over Friedewald — accurate at low LDL & high TG" },
    { test:"Lp(a)", detail:"Measure once in ALL adults (Class I)\n≥125 nmol/L = risk enhancer; ≥250 nmol/L = ≥2× ASCVD risk" },
    { test:"ApoB (Class IIa)", detail:"Use in ASCVD, T2DM, elevated TG, or LDL-C/ApoB discordance\nVery high-risk goal: ApoB <55 mg/dL" },
    { test:"hsCRP", detail:"If ≥2 mg/L on 2 occasions (no cause) → consider high-intensity statin\nTip for borderline/intermediate risk patients" },
    { test:"Secondary cause workup", detail:"TSH (hypothyroidism) · HbA1c/glucose (T2DM)\nCreatinine/eGFR + urine protein (CKD/nephrotic) · LFTs · LFTs for statin monitoring" },
  ];

  labs.forEach((lab, i) => {
    const y = 1.43 + i * 0.58;
    s.addShape(pres.ShapeType.roundRect, { x: 5.08, y: y, w: 1.45, h: 0.4, fill: { color: C.navy }, rectRadius: 0.06 });
    s.addText(lab.test, { x: 5.08, y: y, w: 1.45, h: 0.4, fontSize: 7.5, bold: true, color: C.white, align: "center", valign: "middle", margin: 3 });
    s.addText(lab.detail, { x: 6.58, y: y - 0.04, w: 3.07, h: 0.58, fontSize: 8, color: C.gray, valign: "middle", margin: 2 });
  });

  footer(s, 6);
}

// ─── SLIDE 11: LIPID TARGETS TABLE ───────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.ice } });
  titleBar(s, "AHA 2026 — LDL-C & Non-HDL-C Treatment Targets", "Risk-based goals restored — return of numeric targets");

  const tRows = [
    { risk:"VERY HIGH RISK", detail:"Clinical ASCVD + ≥2 major events OR 1 major event + ≥2 high-risk conditions", ldl:"< 55 mg/dL\n(1.4 mmol/L)", nhdl:"< 85 mg/dL\n(2.2 mmol/L)", red:C.red, reduction:"≥50% from baseline" },
    { risk:"HIGH RISK", detail:"Clinical ASCVD not very high risk; OR High primary prevention (ASCVD risk ≥10%)", ldl:"< 70 mg/dL\n(1.8 mmol/L)", nhdl:"< 100 mg/dL\n(2.6 mmol/L)", red:C.orange, reduction:"≥50% from baseline" },
    { risk:"INTERMEDIATE RISK", detail:"Primary prevention 5–<10% ASCVD risk; OR Diabetes without other risk factors", ldl:"< 100 mg/dL\n(2.6 mmol/L)", nhdl:"< 130 mg/dL\n(3.4 mmol/L)", red:C.gold, reduction:"30–49% reduction" },
    { risk:"BORDERLINE RISK", detail:"Primary prevention 3–<5% ASCVD risk; use risk enhancers to decide on therapy", ldl:"< 100 mg/dL\n(2.6 mmol/L)", nhdl:"< 130 mg/dL\n(3.4 mmol/L)", red:C.green, reduction:"30–49% reduction" },
    { risk:"LOW RISK", detail:"ASCVD risk <3%; young adults (30–59 yrs); counsel on lifestyle; consider statin if LDL 160–189 or 30-yr risk ≥10%", ldl:"Lifestyle first;\nStatin if LDL\n160–189", nhdl:"Consider statin\nif 30-yr risk ≥10%", red:C.teal, reduction:"Lifestyle ± 30–49%" },
    { risk:"LDL ≥190 mg/dL\n(Severe Hypercholest.)", detail:"Regardless of ASCVD risk — likely FH; screen family; treat aggressively", ldl:"< 100 mg/dL\n(+risk factors: <70)", nhdl:"< 130 mg/dL\n(+risk: <100)", red:C.navy, reduction:"Max statin + add-on" },
  ];

  // Header
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 1.08, w: 9.44, h: 0.3, fill: { color: C.navy } });
  ["Risk Category","Clinical Scenario","LDL-C Target","Non-HDL-C","% Reduction"].forEach((h, i) => {
    const xA = [0.3, 1.8, 5.8, 7.3, 8.6];
    const wA = [1.45, 3.95, 1.45, 1.25, 1.1];
    s.addText(h, { x: xA[i], y: 1.08, w: wA[i], h: 0.3, fontSize: 8.5, bold: true, color: C.white, valign: "middle", margin: 2 });
  });

  tRows.forEach((r, i) => {
    const y = 1.38 + i * 0.68;
    const bg = i % 2 === 0 ? C.white : "EBF5FB";
    s.addShape(pres.ShapeType.rect, { x: 0.28, y, w: 9.44, h: 0.68, fill: { color: bg } });
    // Risk badge
    s.addShape(pres.ShapeType.roundRect, { x: 0.32, y: y + 0.1, w: 1.4, h: 0.48, fill: { color: r.red }, rectRadius: 0.07 });
    s.addText(r.risk, { x: 0.32, y: y + 0.1, w: 1.4, h: 0.48, fontSize: 7.5, bold: true, color: C.white, align: "center", valign: "middle", margin: 3 });
    s.addText(r.detail, { x: 1.8, y, w: 3.95, h: 0.68, fontSize: 8, color: C.gray, valign: "middle", margin: 3 });
    s.addText(r.ldl, { x: 5.8, y, w: 1.4, h: 0.68, fontSize: 9, bold: true, color: r.red, align: "center", valign: "middle", margin: 2 });
    s.addText(r.nhdl, { x: 7.3, y, w: 1.25, h: 0.68, fontSize: 8.5, color: C.navy, align: "center", valign: "middle", margin: 2 });
    s.addText(r.reduction, { x: 8.6, y, w: 1.1, h: 0.68, fontSize: 8, color: C.teal, align: "center", valign: "middle", margin: 2 });
  });
  footer(s, 7);
}

// ─── SLIDE 12: SECTION – TREATMENT ───────────────────────────────────────────
{
  const s = pres.addSlide();
  sectionDivider(s, 5, "Treatment & Management", "Non-pharmacological + Pharmacological — AHA 2026 Algorithm");
}

// ─── SLIDE 13: NON-PHARMACOLOGICAL ───────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.ice } });
  titleBar(s, "Non-Pharmacological Management", "Therapeutic lifestyle change — foundational for ALL risk categories");

  const pillars = [
    { title:"DIET",       color:C.teal,   icon:"🥗",
      items:["Reduce saturated fat <7% total calories; eliminate trans fats entirely","↑ Soluble fiber: oats, beans, psyllium → LDL ↓ 5–10%","Plant stanols/sterols 2 g/day → LDL ↓ ~10%","Mediterranean or DASH diet — strongest CV evidence base","Omega-3 fatty acids (fish) — lower TG; icosapent ethyl for high-risk","Reduce simple carbohydrates/alcohol in hypertriglyceridemia"] },
    { title:"EXERCISE",   color:C.navy,   icon:"🏃",
      items:["≥150 min/week moderate-intensity aerobic (brisk walk, cycling)","Resistance training ≥2×/week","Raises HDL-C by 5–10 mg/dL; lowers TG 20–30%","Reduces insulin resistance (improves small dense LDL pattern)","Start low, go slow — any increase in activity is beneficial"] },
    { title:"WEIGHT",     color:C.green,  icon:"⚖️",
      items:["Each 5–10 kg weight loss: LDL ↓ ~8%, TG ↓ ~20%, HDL ↑ 2–5 mg/dL","GLP-1 receptor agonists (semaglutide): additional TG benefit via weight loss","BMI and waist circumference are included in PREVENT equations","Target BMI <25; waist <102 cm (M), <88 cm (F)"] },
    { title:"LIFESTYLE",  color:C.red,    icon:"🚭",
      items:["Smoking cessation: ↑ HDL, ↓ oxidative modification of LDL","Alcohol restriction: essential for HTG — even moderate intake raises TG","Optimal glycemic control in T2DM: SGLT-2i + GLP-1a reduce ASCVD risk beyond glucose","Stress reduction and sleep optimization improve metabolic profile"] },
  ];

  pillars.forEach((p, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.28 + col * 4.8;
    const y = 1.08 + row * 2.2;
    s.addShape(pres.ShapeType.roundRect, { x, y, w: 4.6, h: 2.1, fill: { color: C.white }, line: { color: p.color, width: 1.5 }, rectRadius: 0.1 });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 0.34, fill: { color: p.color } });
    s.addText(`${p.title}`, { x: x + 0.1, y, w: 4.4, h: 0.34, fontSize: 11, bold: true, color: C.white, valign: "middle", margin: 4 });
    s.addText(p.items.map(it => `• ${it}`).join("\n"), {
      x: x + 0.12, y: y + 0.37, w: 4.35, h: 1.68, fontSize: 8.5, color: C.gray, valign: "top", margin: 4,
    });
  });
  footer(s, 8);
}

// ─── SLIDE 14: PHARMACOLOGICAL – DRUG TABLE ───────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.ice } });
  titleBar(s, "Pharmacological Treatment — Drug Classes (AHA 2026)", "Five new FDA-approved therapies incorporated into the 2026 guideline");

  const drugs = [
    { cls:"Statins",          mech:"HMG-CoA reductase inhibition → ↑ LDL receptors",   agents:"Rosuvastatin, Atorvastatin (high); Simvastatin, Pravastatin (mod/low)", ldl:"30–65%",    role:"FIRST-LINE ALL patients",   color:C.navy },
    { cls:"Ezetimibe",        mech:"↓ NPC1L1 intestinal cholesterol absorption",         agents:"Ezetimibe 10 mg daily",                                                 ldl:"+15–25%",   role:"Add-on step 2",             color:C.teal },
    { cls:"PCSK9 mAbs",       mech:"Prevent PCSK9-mediated LDL receptor degradation",    agents:"Evolocumab 140 mg Q2W; Alirocumab 75–150 mg Q2W",                       ldl:"+50–65%",   role:"Very high / high risk; add-on step 3", color:C.red },
    { cls:"Inclisiran",       mech:"siRNA → ↓ hepatic PCSK9 synthesis",                 agents:"Inclisiran 284 mg SC — Day 1, Day 90, then Q6M",                        ldl:"+~50%",     role:"Alternative to PCSK9 mAb (AHA 2026)", color:C.orange },
    { cls:"Bempedoic Acid",   mech:"↓ ATP-citrate lyase (upstream HMG-CoA) → ↓ chol",  agents:"Bempedoic acid 180 mg daily (oral)",                                    ldl:"+15–25%",   role:"Statin-intolerant; add-on option",   color:C.green },
    { cls:"Bile Acid Seques.", mech:"Bind bile acids → ↑ LDL receptor upregulation",   agents:"Cholestyramine 4–24 g; Colesevelam 3.75 g",                             ldl:"15–30%",    role:"Limited use; ↑ TG, GI SE",          color:C.gray },
    { cls:"Fibrates",         mech:"PPAR-α agonist → ↓ VLDL secretion, ↑ LPL activity",agents:"Fenofibrate 145 mg; avoid gemfibrozil with statin (myopathy)",           ldl:"TG↓30–50%", role:"TG ≥500 mg/dL; pancreatitis prevention", color:C.teal },
    { cls:"Icosapent ethyl",  mech:"Pure EPA → ↓ VLDL secretion + anti-inflammatory",  agents:"Icosapent ethyl 4 g/day (2 g BID with meals)",                          ldl:"TG↓20–40%", role:"High/very high risk + TG ≥150; REDUCE-IT trial", color:C.navy },
    { cls:"Evinacumab",       mech:"Anti-ANGPTL3 mAb → ↓ LDL independent of LDL-R",   agents:"Evinacumab 15 mg/kg IV monthly",                                        ldl:"+~50%",     role:"Homozygous FH only (AHA 2026 COR 2b)", color:C.red },
    { cls:"Lomitapide",       mech:"↓ MTP → ↓ VLDL/chylomicron assembly",             agents:"Lomitapide 5–60 mg daily (titrate); LFT monitoring",                    ldl:"40–50%",    role:"Homozygous FH only",                color:C.orange },
  ];

  const headers = ["Drug Class","Mechanism","Key Agents","LDL↓","Role / Indication"];
  const hX =     [0.28, 1.8, 4.05, 6.95, 7.6];
  const hW =     [1.48, 2.2, 2.85, 0.6, 2.15];

  s.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.08, w: 9.5, h: 0.27, fill: { color: C.navy } });
  headers.forEach((h, i) => {
    s.addText(h, { x: hX[i], y: 1.08, w: hW[i], h: 0.27, fontSize: 8, bold: true, color: C.white, valign: "middle", margin: 2 });
  });

  drugs.forEach((d, i) => {
    const y = 1.35 + i * 0.43;
    const bg = i % 2 === 0 ? C.white : "EBF5FB";
    s.addShape(pres.ShapeType.rect, { x: 0.25, y, w: 9.5, h: 0.43, fill: { color: bg } });
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: y + 0.06, w: 1.4, h: 0.3, fill: { color: d.color }, rectRadius: 0.05 });
    s.addText(d.cls, { x: 0.3, y: y + 0.06, w: 1.4, h: 0.3, fontSize: 7.5, bold: true, color: C.white, align: "center", valign: "middle", margin: 2 });
    s.addText(d.mech, { x: 1.82, y, w: 2.18, h: 0.43, fontSize: 7.5, color: C.gray, valign: "middle", margin: 2 });
    s.addText(d.agents, { x: 4.07, y, w: 2.82, h: 0.43, fontSize: 7.5, color: C.navy, valign: "middle", margin: 2 });
    s.addText(d.ldl, { x: 6.97, y, w: 0.58, h: 0.43, fontSize: 8, bold: true, color: d.color, align: "center", valign: "middle", margin: 2 });
    s.addText(d.role, { x: 7.62, y, w: 2.1, h: 0.43, fontSize: 7.5, color: C.gray, valign: "middle", margin: 2 });
  });
  footer(s, 9);
}

// ─── SLIDE 15: TREATMENT ALGORITHM ───────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.ice } });
  titleBar(s, "AHA 2026 — Stepwise Treatment Algorithm", "Risk-stratified lipid-lowering therapy (LLT) approach");

  // Step-up boxes left column
  const steps = [
    { n:"Step 1", label:"Therapeutic Lifestyle Change", color:C.green,
      text:"ALL patients — diet, exercise, weight loss, smoking cessation\nFoundation regardless of pharmacotherapy" },
    { n:"Step 2", label:"Statin (1st-line pharmacotherapy)", color:C.navy,
      text:"High-intensity: Atorva 40–80 mg or Rosuva 20–40 mg → ≥50% LDL↓\nModerate-intensity: Atorva 10–20 mg, Rosuva 5–10 mg → 30–49% LDL↓" },
    { n:"Step 3", label:"Add Ezetimibe 10 mg", color:C.teal,
      text:"If LDL-C goal not achieved on maximally tolerated statin\nAdds 15–25% further LDL-C reduction" },
    { n:"Step 4", label:"Add Non-statin LLT", color:C.red,
      text:"PCSK9 mAb (evolocumab/alirocumab) OR inclisiran (Q6M injection)\nOR bempedoic acid (statin-intolerant)\nOR combination, guided by how far from goal" },
  ];

  steps.forEach((st, i) => {
    const y = 1.08 + i * 1.08;
    s.addShape(pres.ShapeType.roundRect, { x: 0.28, y, w: 0.6, h: 0.85, fill: { color: st.color }, rectRadius: 0.08 });
    s.addText(st.n, { x: 0.28, y, w: 0.6, h: 0.85, fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle", margin: 2 });
    s.addShape(pres.ShapeType.roundRect, { x: 0.95, y, w: 5.6, h: 0.85, fill: { color: C.white }, line: { color: st.color, width: 1.5 }, rectRadius: 0.08 });
    s.addText(st.label, { x: 1.05, y: y + 0.04, w: 5.4, h: 0.25, fontSize: 10, bold: true, color: st.color, margin: 4 });
    s.addText(st.text, { x: 1.05, y: y + 0.3, w: 5.4, h: 0.52, fontSize: 8.5, color: C.gray, margin: 4 });
    if (i < 3) {
      s.addShape(pres.ShapeType.rect, { x: 0.54, y: y + 0.85, w: 0.12, h: 0.23, fill: { color: C.lgray } });
    }
  });

  // Right column: special scenarios
  const scenarios = [
    { title:"Statin Intolerant", color:C.orange, text:"Bempedoic acid (oral) — Class I in ESC, option in AHA\nEzetimibe + PCSK9 mAb\nInclisiran as PCSK9 mAb alternative" },
    { title:"Post-ACS (very high risk)", color:C.red, text:"Initiate high-intensity statin during hospitalization\nAdd ezetimibe ± PCSK9 mAb if LDL >55 mg/dL at discharge\nDo NOT wait for outpatient follow-up" },
    { title:"Familial Hypercholesterolemia", color:C.navy, text:"HeFH: Max statin + ezetimibe + PCSK9 mAb\nHoFH: Add evinacumab or lomitapide; consider LDL apheresis if LDL ≥100 on max therapy\nTarget LDL <70 (HeFH) or <100 mg/dL (HoFH)" },
    { title:"Hypertriglyceridemia", color:C.teal, text:"TG 150–499: lifestyle, address secondary causes; icosapent ethyl if high-risk\nTG ≥500: fibrate (fenofibrate) ± omega-3 to prevent pancreatitis\nTG ≥1000: hospitalize; very low fat diet; insulin if DM" },
  ];

  scenarios.forEach((sc, i) => {
    const y = 1.08 + i * 1.08;
    s.addShape(pres.ShapeType.roundRect, { x: 6.75, y, w: 3.1, h: 1.0, fill: { color: C.white }, line: { color: sc.color, width: 1.5 }, rectRadius: 0.1 });
    s.addShape(pres.ShapeType.rect, { x: 6.75, y, w: 3.1, h: 0.3, fill: { color: sc.color } });
    s.addText(sc.title, { x: 6.8, y, w: 3.0, h: 0.3, fontSize: 9, bold: true, color: C.white, valign: "middle", margin: 4 });
    s.addText(sc.text, { x: 6.8, y: y + 0.33, w: 3.0, h: 0.63, fontSize: 7.5, color: C.gray, valign: "top", margin: 3 });
  });

  footer(s, 10);
}

// ─── SLIDE 16: STATIN INTENSITY ───────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.ice } });
  titleBar(s, "Statin Intensity Classification & Side Effects", "Intensity guided by absolute ASCVD risk — not lipid level alone");

  // Three intensity columns
  const intensities = [
    { label:"HIGH INTENSITY", target:"≥50% LDL-C reduction",  color:C.red,
      drugs:["Atorvastatin 40 mg → ~49% LDL↓","Atorvastatin 80 mg → ~60% LDL↓","Rosuvastatin 20 mg → ~52% LDL↓","Rosuvastatin 40 mg → ~55% LDL↓"],
      use:"Clinical ASCVD (all)\nHigh primary prevention (≥10%)\nLDL-C ≥190 mg/dL" },
    { label:"MODERATE INTENSITY", target:"30–49% LDL-C reduction", color:C.orange,
      drugs:["Atorvastatin 10 mg → ~37% LDL↓","Rosuvastatin 5–10 mg → ~38% LDL↓","Simvastatin 20–40 mg → ~35% LDL↓","Pravastatin 40–80 mg → ~34% LDL↓","Fluvastatin 40–80 mg → ~25% LDL↓"],
      use:"Intermediate primary prevention (5–<10%)\nBorderline risk with enhancers\nDiabetes (varies by risk)" },
    { label:"LOW INTENSITY", target:"<30% LDL-C reduction", color:C.green,
      drugs:["Simvastatin 10 mg","Pravastatin 10–20 mg","Lovastatin 20 mg"],
      use:"Statin-intolerant patients on partial therapy\nRarely first-choice — use moderate instead if tolerated" },
  ];

  intensities.forEach((inten, i) => {
    const x = 0.28 + i * 3.2;
    s.addShape(pres.ShapeType.roundRect, { x, y: 1.08, w: 3.1, h: 3.2, fill: { color: C.white }, line: { color: inten.color, width: 2 }, rectRadius: 0.12 });
    s.addShape(pres.ShapeType.rect, { x, y: 1.08, w: 3.1, h: 0.52, fill: { color: inten.color } });
    s.addText(inten.label, { x: x + 0.08, y: 1.08, w: 2.94, h: 0.3, fontSize: 10, bold: true, color: C.white, align: "center", margin: 4 });
    s.addText(`Target: ${inten.target}`, { x: x + 0.08, y: 1.36, w: 2.94, h: 0.24, fontSize: 8.5, color: C.white, align: "center", margin: 2 });
    s.addText("Drugs:", { x: x + 0.1, y: 1.64, w: 2.9, h: 0.22, fontSize: 8.5, bold: true, color: inten.color, margin: 2 });
    s.addText(inten.drugs.map(d => `• ${d}`).join("\n"), { x: x + 0.1, y: 1.84, w: 2.9, h: 1.2, fontSize: 8.5, color: C.gray, valign: "top", margin: 2 });
    s.addShape(pres.ShapeType.rect, { x: x + 0.1, y: 3.0, w: 2.9, h: 0.02, fill: { color: C.lgray } });
    s.addText("Use for:", { x: x + 0.1, y: 3.06, w: 2.9, h: 0.2, fontSize: 8.5, bold: true, color: inten.color, margin: 2 });
    s.addText(inten.use, { x: x + 0.1, y: 3.25, w: 2.9, h: 0.8, fontSize: 8.5, color: C.gray, valign: "top", margin: 2 });
  });

  // Side effects box
  s.addShape(pres.ShapeType.roundRect, { x: 0.28, y: 4.38, w: 9.44, h: 0.95, fill: { color: C.white }, line: { color: C.red, width: 1 }, rectRadius: 0.1 });
  s.addShape(pres.ShapeType.rect, { x: 0.28, y: 4.38, w: 9.44, h: 0.28, fill: { color: C.red } });
  s.addText("⚠  Statin Safety & Side Effects", { x: 0.35, y: 4.38, w: 9.3, h: 0.28, fontSize: 9, bold: true, color: C.white, valign: "middle", margin: 4 });
  s.addText(
    "• Myopathy / Myalgia (most common) — check CK if symptomatic; switch statin or reduce dose\n" +
    "• Rhabdomyolysis (rare) — CK >10× ULN; discontinue immediately | Hepatotoxicity (rare) — monitor LFTs at baseline\n" +
    "• New-onset T2DM (~10% risk over 4 yrs on high-intensity; benefits outweigh risk in high-risk patients)\n" +
    "• Drug interactions: Avoid simvastatin >20 mg with strong CYP3A4 inhibitors (clarithromycin, itraconazole); gemfibrozil + statin → myopathy risk",
    { x: 0.35, y: 4.66, w: 9.3, h: 0.63, fontSize: 8, color: C.gray, valign: "top", margin: 2 }
  );
  footer(s, 11);
}

// ─── SLIDE 17: SECTION – SPECIAL POPULATIONS ──────────────────────────────────
{
  const s = pres.addSlide();
  sectionDivider(s, 6, "Special Populations", "Diabetes · CKD · Elderly · Pregnancy · HIV · FH · Children");
}

// ─── SLIDE 18: SPECIAL POPULATIONS ────────────────────────────────────────────
{
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  titleBar(s, "Management in Special Populations", "AHA 2026 guidance for specific clinical groups");

  const pops = [
    { title:"Type 2 Diabetes", color:C.orange,
      text:"Most T2DM have at least moderate CV risk → statin therapy indicated\nT2DM age 40–75 at high risk: high-intensity statin → LDL-C <70 mg/dL\nAdd SGLT-2i or GLP-1RA for additional ASCVD + renal protection\nPattern: ↑ TG, ↓ HDL, small dense LDL — address all components" },
    { title:"Chronic Kidney Disease", color:C.teal,
      text:"CKD stage 3–5 (not on dialysis): moderate or high-intensity statin\nOn dialysis: initiate new statin not beneficial; continue if already on\nNephrotic syndrome → severe secondary hyperlipidemia — treat underlying\nAvoid high-dose simvastatin (myopathy risk in CKD)" },
    { title:"Elderly (≥75 years)", color:C.navy,
      text:"Continue statin if already on therapy with established ASCVD\nPrimary prevention in >75 yrs: individualize — discuss risk/benefit, polypharmacy, frailty\nRisk of statin side effects higher in elderly (myopathy, DDI)\nCAC, functional status, life expectancy guide decisions" },
    { title:"Pregnancy", color:C.red,
      text:"Statins CONTRAINDICATED in pregnancy (teratogenic — Category X)\nDiscontinue 1–3 months before planned conception\nBile acid sequestrants (colesevelam) safest option if needed\nHypertriglyceridemia in pregnancy: very low fat diet; omega-3; fenofibrate if TG >1000 (pancreatitis risk)" },
    { title:"HIV / Chronic Inflammation", color:C.green,
      text:"HIV: dyslipidemia from both disease + ART (PIs raise TG/LDL most)\nUse pravastatin or rosuvastatin (less CYP3A4 interaction with PIs)\nAvoid simvastatin/lovastatin with PI boosted regimens\nRA, psoriasis, SLE: CV risk enhancers → lower threshold for statin" },
    { title:"Children & Adolescents", color:C.gold,
      text:"Universal lipid screening at age 9–11 yrs (AHA 2026 — NEW Class I)\nFH: LDL-C ≥160 mg/dL in child → screen family; statin if ≥8–10 yrs\nLifestyle foundation: diet + exercise first for 3–6 months\nLDL ≥190 mg/dL in adolescent + family hx → consider statin referral" },
  ];

  pops.forEach((p, i) => {
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    const row = Math.floor(i / 3);
    // 3 per column, 2 columns
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  footer(s, 12);
}

// ─── SLIDE 19: KEY TAKEAWAYS ─────────────────────────────────────────────────
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  s.addText("KEY TAKEAWAYS", { x: 0.4, y: 0.18, w: 9, h: 0.6, fontSize: 28, bold: true, color: C.white, charSpacing: 4, margin: 0 });
  s.addText("ACC / AHA 2026 Dyslipidemia Guideline — 10 Points Every Clinician Must Know", {
    x: 0.4, y: 0.78, w: 9, h: 0.38, fontSize: 12, color: C.gold, italic: true, margin: 0,
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  const takeaways = [
    { n:"1", text:"LDL-C targets are back: <55 (very high), <70 (high), <100 (intermediate) mg/dL" },
    { n:"2", text:"Use PREVENT (not PCE) — estimates 10-yr ASCVD risk for ages 30–79; runs 40–50% lower than old PCE" },
    { n:"3", text:"Measure Lp(a) at least once in ALL adults (Class I) — ≥125 nmol/L = risk enhancer; act on it" },
    { n:"4", text:"CAC >0 → initiate LLT (Class I); CAC = 0 + no high-risk conditions → defer, repeat in 3–7 yrs" },
    { n:"5", text:"Statin = first-line always; high-intensity for high/very high risk; titrate to goal" },
    { n:"6", text:"Step up: Statin → + Ezetimibe → + PCSK9 mAb / Inclisiran / Bempedoic acid" },
    { n:"7", text:"Inclisiran (siRNA): twice-yearly injection — equivalent to PCSK9 mAb; now formally recommended" },
    { n:"8", text:"Icosapent ethyl (pure EPA 4 g/day) for high/very high risk patients with TG ≥150 mg/dL on statin" },
    { n:"9", text:"Universal pediatric lipid screening at age 9–11 — screen family if child has LDL ≥160" },
    { n:"10", text:"New ApoB targets: <55 mg/dL (very high risk) — use when LDL-C and ApoB are discordant" },
  ];

  takeaways.forEach((t, i) => {
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// ─── SAVE ─────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/dyslipidemia-aha2026/Dyslipidemia_AHA2026.pptx" })
  .then(() => console.log("DONE: Dyslipidemia_AHA2026.pptx saved"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });