Physical Rehabilitation: A Complete Guide

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      // ─── TITLE PAGE ──────────────────────────────────────────────────────────
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        children: [
          new TextRun({ text: "CARDIAC REHABILITATION", bold: true, size: 52, color: WHITE, font: "Calibri", break: 1 }),
          new TextRun({ text: "Phases, Exercise Progression & Clinical Protocols", size: 32, color: "A9CCE3", font: "Calibri", break: 1 }),
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          new TextRun({ text: "Based on Fuster & Hurst's The Heart (15th Ed.) • Braunwald's Heart Disease • StatPearls • AHA/ACC Guidelines", size: 16, color: "D6EAF8", font: "Calibri", break: 1 }),
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      // ─── SECTION 1: OVERVIEW ─────────────────────────────────────────────────
      h1("1. OVERVIEW OF CARDIAC REHABILITATION"),
      spacer(),
      body("Cardiac rehabilitation (CR) is a clinically proven, multidisciplinary secondary prevention program for patients with cardiovascular disease (CVD). It combines supervised exercise training, risk factor modification, patient education, dietary counseling, and psychosocial support. The program enhances survival, reduces the risk of recurrent cardiac events, and improves both physical and psychological well-being."),
      spacer(),
      body("Historically, myocardial infarction (MI) was managed with up to 6-8 weeks of strict bedrest, leading to unnecessary deconditioning. In the early 1950s, Levine and Lown pioneered early 'armchair' ambulation within 1 day of acute MI. This marked the beginning of modern cardiac rehabilitation."),
      spacer(),

      h2("1.1 The Five Core Competencies of Cardiac Rehabilitation"),
      spacer(),
      makeTable(
        ["Core Competency", "Description", "Examples"],
        [
          ["Exercise Training", "Supervised aerobic & resistance exercise tailored to the individual", "Treadmill walking, cycling, resistance bands"],
          ["Patient Education", "Disease knowledge, medications, warning signs, self-monitoring", "Group lectures, written materials, one-on-one counseling"],
          ["Dietary Counseling", "Individualized heart-healthy nutrition planning", "Mediterranean diet, sodium/fat restriction, weight management"],
          ["Psychosocial Interventions", "Addressing depression, anxiety, social support, stress management", "Cognitive behavioral therapy, group therapy, relaxation training"],
          ["Risk Factor Modification", "Managing hypertension, dyslipidemia, diabetes, smoking", "Medication adherence, smoking cessation, BP/lipid targets"],
        ],
        [22, 42, 36]
      ),
      spacer(),

      h2("1.2 Program Structure & Delivery Formats"),
      bullet("Standard US/Canada format: 36 sessions over 12-18 weeks (2-3 sessions/week)"),
      bullet("Worldwide median: 24 supervised sessions (58% of programs offer ≥12 sessions)"),
      bullet("Home-based programs: Median 6 sessions — growing in use post-COVID"),
      bullet("Hybrid programs: Combination of center-based + home-based supervision"),
      bullet("Each session: 5-10 min warm-up + 20-40 min aerobic training + 10 min cool-down + education"),
      bullet("All Phase 2 sessions are ECG-monitored"),
      spacer(),

      h2("1.3 Eligible Indications (ACC/AHA 2018)"),
      makeTable(
        ["Indication", "Details"],
        [
          ["Non-ST elevation ACS (NSTEMI/UA)", "Following stabilization and revascularization"],
          ["ST-elevation MI (STEMI)", "After primary PCI or thrombolysis"],
          ["Coronary Artery Bypass Grafting (CABG)", "All patients post-CABG surgery"],
          ["Percutaneous Coronary Intervention (PCI)", "Following any PCI procedure"],
          ["Valvular Surgery", "Replacement or repair of cardiac valves"],
          ["Cardiac Transplantation", "Including heart-lung transplantation"],
          ["Stable Angina Pectoris", "Chronic stable ischemic heart disease"],
          ["Peripheral Vascular Disease (PVD)", "With significant functional limitation"],
          ["Heart Failure with Reduced EF (HFrEF)", "Medicare-approved indication since 2014"],
        ],
        [35, 65]
      ),
      spacer(),

      h2("1.4 Absolute Contraindications (Fuster & Hurst's The Heart, 15th Ed.)"),
      makeTable(
        ["Contraindication", "Rationale"],
        [
          ["Worsening chest pain / Unstable angina", "Risk of MI during exertion"],
          ["Decompensated heart failure", "Hemodynamic instability"],
          ["Recent stroke or TIA", "Risk of extension or hemorrhagic transformation"],
          ["Atrial arrhythmia with uncontrolled ventricular response", "Inadequate cardiac output during exercise"],
          ["Complex ventricular arrhythmia", "Risk of fatal arrhythmia during exertion"],
          ["Severe pulmonary arterial hypertension", "Right ventricular strain with exercise"],
          ["Intracavitary thrombus", "Risk of embolization during exertion"],
          ["Recent thrombophlebitis or pulmonary embolism", "Risk of worsening thromboembolism"],
          ["Severe obstructive cardiomyopathy (HOCM)", "Dynamic LVOT obstruction worsens with exertion"],
          ["Symptomatic or severe aortic stenosis", "Fixed obstruction — sudden cardiac death risk"],
          ["Acute infection or febrile illness", "Systemic inflammation, increased metabolic demand"],
          ["Inability to exercise (musculoskeletal)", "Functional impossibility"],
          ["Cognitive dysfunction preventing compliance", "Safety monitoring not feasible"],
        ],
        [45, 55]
      ),
      spacer(),

      pageBreak(),

      // ─── SECTION 2: PHASES ───────────────────────────────────────────────────
      h1("2. THE PHASES OF CARDIAC REHABILITATION"),
      spacer(),
      body("Cardiac rehabilitation is organized into three primary phases (with some systems using four phases). Each phase builds upon the previous, progressing from acute inpatient care to lifelong community-based maintenance. The transition between phases is guided by clinical stability, exercise tolerance, and patient readiness."),
      spacer(),

      // PHASE 1
      phaseBox("I", "INPATIENT REHABILITATION", "Acute Hospital Phase  |  Days 1-7 (until discharge)", "1B3A6B"),
      spacer(),

      h3("Goals of Phase I"),
      bullet("Prevent deconditioning and complications of prolonged bedrest"),
      bullet("Begin early mobilization when hemodynamically stable"),
      bullet("Prevent deep venous thrombosis (DVT) and pulmonary embolism"),
      bullet("Educate patient and family about the cardiac event and recovery"),
      bullet("Establish a safe home exercise plan for discharge"),
      bullet("Bridge to outpatient Phase II enrollment"),
      bullet("Psychological support — address anxiety, depression, fear"),
      spacer(),

      h3("Exercise Protocol: Phase I Daily Progression"),
      makeTable(
        ["Day", "Activity Level", "Exercise Description", "Monitoring", "Goals"],
        [
          ["Day 1\n(ICU/CCU)", "Minimal mobilization", "Passive range of motion (ROM); leg exercises in bed; breathing exercises (diaphragmatic, deep breathing)", "Continuous ECG telemetry; BP every 15 min", "Prevent atelectasis, DVT, pressure ulcers"],
          ["Day 2", "Passive → Active-assist", "Active-assisted ROM; sitting at edge of bed (dangling); bed-to-chair transfer; seated upper/lower limb movements", "Telemetry; SpO2; BP before/after", "Achieve orthostatic tolerance"],
          ["Day 3", "Standing & limited ambulation", "Standing with support; ambulate 50-100 m in corridor; self-care activities (washing, dressing)", "Spot ECG checks; nurse supervision", "Independent ambulation short distance"],
          ["Day 4-5", "Progressive ambulation", "Walk 100-200 m twice daily; stair climbing 1 flight (with supervision); self-care without assistance", "BP and HR before/after activity; supervised", "Ambulate hallway independently"],
          ["Day 6-7\n(Pre-discharge)", "Functional ambulation", "Walk 200-400 m; stair climbing; discharge exercise instruction; home walking plan prescribed", "Discharge exercise test (if indicated); education session", "Safe for home discharge; knows home exercise plan"],
        ],
        [10, 14, 30, 22, 24]
      ),
      spacer(),

      h3("Exercise Intensity Parameters: Phase I"),
      makeTable(
        ["Parameter", "Target Range", "Stop Criteria"],
        [
          ["Heart Rate (HR)", "Resting HR + 20-30 bpm; or <120 bpm post-MI; <130 bpm post-CABG", "HR >130 bpm or >30 bpm above resting"],
          ["Blood Pressure (BP)", "SBP rise <40 mmHg; DBP rise <20 mmHg from rest", "SBP >200 or <90 mmHg; DBP >110 mmHg"],
          ["Rate of Perceived Exertion (RPE)", "Borg Scale 11-13 (Light to Somewhat Hard)", "RPE >15 (Hard)"],
          ["SpO2 (Oxygen Saturation)", ">94% throughout activity", "<90% — suspend activity"],
          ["METs (Metabolic Equivalents)", "1.0-3.0 METs (very light to light activity)", ">3.5 METs unless cleared"],
        ],
        [22, 38, 40]
      ),
      spacer(),

      h3("Phase I: Education Components"),
      bullet("Anatomy and physiology of the heart and coronary arteries"),
      bullet("Explanation of the cardiac event (MI, CABG, valve repair)"),
      bullet("Understanding of medications: beta-blockers, statins, antiplatelets, ACE inhibitors"),
      bullet("Warning signs requiring emergency attention (chest pain, dyspnea, syncope)"),
      bullet("Wound care instructions (sternotomy/PCI access site)"),
      bullet("Sexual activity and return to driving guidelines"),
      bullet("Dietary modifications: sodium, saturated fat, cholesterol restriction"),
      bullet("Smoking cessation counseling and resources"),
      bullet("Introduction to Phase II outpatient program"),
      spacer(),

      colorBox("NOTE:", "Formal Phase I inpatient programs in the United States have largely devolved due to the current short duration of hospital stays following acute MI and revascularization procedures. The focus is now on early mobilization, patient education, and seamless transition to outpatient Phase II.", LIGHT_BLUE, DARK_BLUE),
      spacer(),

      // PHASE 2
      phaseBox("II", "OUTPATIENT SUPERVISED REHABILITATION", "Early Recovery Phase  |  Weeks 1-12 (36 Sessions)", "2E6DA4"),
      spacer(),

      h3("Goals of Phase II"),
      bullet("Improve cardiorespiratory fitness (VO2 peak/VO2 max) through supervised exercise"),
      bullet("Reduce modifiable cardiovascular risk factors"),
      bullet("Achieve and maintain heart-healthy lifestyle behaviors"),
      bullet("Psychological rehabilitation: reduce depression and anxiety"),
      bullet("Optimize medication adherence and dose titration"),
      bullet("Prepare patient for independent Phase III maintenance"),
      spacer(),

      h3("Phase II Program Structure"),
      bullet("Duration: Typically 36 sessions over 12-18 weeks"),
      bullet("Frequency: 2-3 sessions per week"),
      bullet("Setting: Supervised outpatient cardiac rehabilitation center"),
      bullet("Monitoring: Continuous ECG telemetry during all exercise sessions"),
      bullet("Each session = Warm-up (5-10 min) + Aerobic training (20-40 min) + Cool-down (5-10 min)"),
      bullet("Educational sessions and risk factor counseling integrated into each visit"),
      spacer(),

      h3("Pre-Phase II Assessment"),
      makeTable(
        ["Assessment", "Method", "Purpose"],
        [
          ["Cardiopulmonary Exercise Test (CPET)", "Symptom-limited treadmill or cycle ergometer with 12-lead ECG", "Establish VO2 peak, training heart rate, METs capacity, identify arrhythmias"],
          ["Modified Exercise Tolerance Test", "Sub-maximal protocol if full CPET unavailable", "Safe exercise prescription when full CPET not feasible"],
          ["Resting ECG", "12-lead ECG", "Baseline rhythm, ischemia, LVH"],
          ["Echocardiography", "Transthoracic echo", "EF assessment, wall motion abnormality, valvular function"],
          ["Risk Stratification", "AHA risk stratification (low/moderate/high)", "Determine level of supervision required"],
          ["Body Composition", "BMI, waist circumference", "Obesity management goals"],
          ["Psychosocial Screening", "PHQ-9, GAD-7, or similar validated tools", "Identify depression/anxiety needing intervention"],
          ["Lipid Profile, HbA1c, BP", "Laboratory and clinical assessment", "Risk factor baseline and monitoring targets"],
        ],
        [25, 30, 45]
      ),
      spacer(),

      h3("AHA Risk Stratification for Phase II Supervision"),
      makeTable(
        ["Risk Category", "Characteristics", "Supervision Level"],
        [
          ["Low Risk", "No significant LV dysfunction (EF >50%), no complex arrhythmias, no ST changes at <6 METs, no angina at <6 METs, asymptomatic at rest", "ECG monitoring first 6-12 sessions; then periodic"],
          ["Moderate Risk", "Mildly impaired LV function (EF 40-49%), mild-moderate angina on exertion, ST depression 1-2 mm, capacity <6 METs", "ECG monitoring first 12-18 sessions"],
          ["High Risk", "EF <40%, complex ventricular arrhythmias, exercise-induced significant ST depression >2 mm, severe angina, prior cardiac arrest, hemodynamic instability", "Continuous ECG monitoring all sessions; physician on-site"],
        ],
        [18, 52, 30]
      ),
      spacer(),

      h3("Exercise Prescription: Phase II — Aerobic Training"),
      makeTable(
        ["FITT Component", "Starting (Weeks 1-3)", "Mid-Program (Weeks 4-8)", "End of Program (Weeks 9-12)"],
        [
          ["Frequency", "2-3 sessions/week", "3 sessions/week", "3-5 sessions/week (including home sessions)"],
          ["Intensity", "40-60% HRR or HRmax; Borg RPE 11-13", "50-70% HRR or HRmax; Borg RPE 12-14", "60-80% HRR or HRmax; Borg RPE 13-15"],
          ["Time (Duration)", "15-20 minutes continuous or intermittent", "20-30 minutes continuous", "30-45 minutes continuous"],
          ["Type (Mode)", "Treadmill walking, stationary cycling", "Treadmill, cycling, elliptical, rowing", "All modes including interval training"],
          ["MET Equivalent", "2-4 METs", "4-6 METs", "5-8 METs (patient-dependent)"],
        ],
        [20, 26, 26, 28]
      ),
      spacer(),

      h3("Exercise Prescription: Phase II — Resistance Training"),
      body("Resistance training is added after 2-4 weeks of aerobic conditioning (or after surgical wound healing, typically 4-6 weeks post-sternotomy)."),
      spacer(),
      makeTable(
        ["Parameter", "Recommendation"],
        [
          ["Frequency", "2-3 days per week (non-consecutive days)"],
          ["Sets & Repetitions", "1-3 sets of 10-15 repetitions per exercise"],
          ["Starting Load", "30-40% of 1-repetition maximum (1RM) for upper body; 50-60% of 1RM for lower body"],
          ["Progression", "Increase load by 5% when patient can complete 15 reps with good form over 2 consecutive sessions"],
          ["Intensity (RPE)", "Borg scale 11-13 (Light to Somewhat Hard); avoid Valsalva maneuver"],
          ["Exercises Included", "Chest press, seated row, shoulder press, bicep curl, tricep extension, leg press, knee extension, hamstring curl, calf raise"],
          ["Post-Sternotomy Precautions", "No upper extremity resistance training for 6-8 weeks; start with lower body only; avoid overhead lifting >5 lbs initially"],
        ],
        [28, 72]
      ),
      spacer(),

      h3("Heart Rate Targets: Phase II"),
      makeTable(
        ["Method", "Formula / Target", "Notes"],
        [
          ["Training Heart Rate (THR) — Karvonen Formula", "THR = [(HRmax - HRrest) × target %] + HRrest\nTarget: 60-80% HRR", "Most accurate; requires resting HR and peak exercise HR from ETT"],
          ["Percentage of Maximum HR (%HRmax)", "THR = HRmax × 0.70-0.85\nHRmax from ETT (not 220-age estimate)", "Simpler; less accurate in patients on beta-blockers"],
          ["Borg Rate of Perceived Exertion (RPE)", "Target: 12-14 on 6-20 Borg scale\n(Somewhat Hard)", "Useful when HR response is blunted (beta-blockers, chronotropic incompetence)"],
          ["Metabolic Equivalents (METs)", "Target: 60-80% of peak METs from ETT", "Used in structured exercise prescription"],
          ["Talk Test", "Patient should be able to speak in short sentences", "Practical field test for moderate intensity"],
        ],
        [28, 44, 28]
      ),
      spacer(),

      colorBox("CLINICAL NOTE:", "In patients on beta-blockers, the HR response to exercise is attenuated. Percentage-of-HRmax formulas are less reliable. Use the Borg RPE scale (target 12-14) or percentage of peak METs from ETT as the primary intensity guide.", "FEF9E7", "B7950B"),
      spacer(),

      h3("Phase II: Exercise Session Structure"),
      makeTable(
        ["Session Component", "Duration", "Activities", "Purpose"],
        [
          ["Warm-Up", "5-10 minutes", "Stretching, light calisthenics, slow walking or cycling at 40-50% HRmax", "Prepare cardiovascular and musculoskeletal systems; prevent arrhythmias from sudden exertion"],
          ["Aerobic Training", "20-40 minutes", "Treadmill, cycle ergometer, elliptical, rowing machine at target HR/RPE", "Improve VO2 peak, cardiac output, peripheral O2 utilization"],
          ["Resistance Training", "10-20 minutes (2-3×/week)", "Weight machines, resistance bands, free weights", "Improve skeletal muscle strength, functional capacity, insulin sensitivity"],
          ["Cool-Down", "5-10 minutes", "Gradual reduction in intensity; slow walking; stretching; relaxation breathing", "Prevent post-exercise hypotension and arrhythmias; promote venous return"],
          ["Education Session", "15-30 minutes (each visit)", "Risk factor review, medication counseling, dietary advice, psychosocial support", "Address all core competencies; improve long-term self-management"],
        ],
        [18, 12, 36, 34]
      ),
      spacer(),

      h3("Signs to Stop Exercise During Phase II"),
      colorBox("STOP EXERCISE IMMEDIATELY if any of the following occur:", "", "FDEDEC", ACCENT_RED),
      bullet("Angina or chest pain/pressure (>3 on scale 0-10)"),
      bullet("Significant shortness of breath disproportionate to workload"),
      bullet("Dizziness, lightheadedness, or near-syncope"),
      bullet("Pallor, diaphoresis, or cyanosis"),
      bullet("HR >target or falls >10 bpm from previous workload (chronotropic incompetence)"),
      bullet("SBP >220 mmHg or falls >10 mmHg during exercise (hemodynamic instability)"),
      bullet("New ECG changes: ST depression >2 mm, new ST elevation, significant arrhythmia"),
      bullet("Patient requests to stop"),
      spacer(),

      h3("High-Intensity Interval Training (HIIT) in Phase II"),
      body("Growing evidence supports the use of HIIT as an alternative or adjunct to moderate continuous exercise in selected Phase II patients. HIIT consists of repeated bouts of high-intensity exercise (85-95% HRmax) interspersed with low-intensity recovery periods."),
      spacer(),
      makeTable(
        ["Aspect", "Details"],
        [
          ["Definition", "Alternating high-intensity intervals (85-95% HRmax or >6 METs) with active recovery periods (50-60% HRmax)"],
          ["Protocol Example", "4 × 4 minutes at 85-95% HRmax with 3-min active recovery at 50-70% HRmax; total 30-40 min session"],
          ["Evidence", "HIIT is more effective than moderate-intensity continuous training for improving VO2 max. HIIT can eliminate non-response to exercise (Ross et al.: 0% non-responders at high volume/intensity vs. ~23% at low intensity)"],
          ["Mortality Benefit", "Each 1-MET increase in aerobic fitness = 13% reduction in mortality risk (Martin et al., 5,641 patients). High responders to CR had 3x lower mortality than non-responders at 6.4-year follow-up (De Schutter et al.)"],
          ["Candidate Selection", "Clinically stable, low-to-moderate risk, normal or mildly impaired EF, adequate baseline exercise capacity (≥4 METs), no complex arrhythmias"],
          ["Caution", "Requires careful risk-benefit assessment in older patients, very low fitness, high comorbidity burden, or significant LV dysfunction"],
        ],
        [25, 75]
      ),
      spacer(),

      pageBreak(),

      // PHASE 3
      phaseBox("III", "INTENSIVE OUTPATIENT MAINTENANCE", "Intermediate Recovery  |  Weeks 12-26+ (Optional/Extended)", "1E6FA0"),
      spacer(),

      h3("Goals of Phase III"),
      bullet("Maintain and consolidate gains in cardiorespiratory fitness from Phase II"),
      bullet("Promote transition toward independent, self-directed exercise"),
      bullet("Reinforce lifestyle modifications and secondary prevention behaviors"),
      bullet("Continue psychosocial support and behavioral change"),
      bullet("Prepare patient for long-term Phase IV maintenance"),
      spacer(),

      h3("Phase III Key Characteristics"),
      body("Phase III programs vary considerably by institution. They may or may not involve medical supervision and generally do not include continuous ECG monitoring during exercise sessions. Group-based sessions foster peer support and social engagement."),
      spacer(),
      makeTable(
        ["Feature", "Details"],
        [
          ["Setting", "Community fitness center, hospital outpatient gym, or home (hybrid)"],
          ["Duration", "Typically 3-6 months; sometimes merges into Phase IV"],
          ["Frequency", "3-5 sessions/week (combination supervised + independent)"],
          ["Monitoring", "Periodic (not continuous) ECG; self-monitoring of HR and RPE encouraged"],
          ["Exercise Focus", "Progressive aerobic training + resistance training + flexibility work"],
          ["Intensity Progression", "70-85% HRmax or 60-80% HRR; Borg RPE 13-15"],
          ["Education", "Reinforcement of risk factor management; stress management; return-to-work counseling"],
          ["Self-Monitoring Skills", "HR monitoring, RPE, symptom recognition, pedometer use, exercise diary"],
        ],
        [25, 75]
      ),
      spacer(),

      h3("Exercise Progression: Phase III"),
      makeTable(
        ["Parameter", "Target at Entry (From Phase II)", "Target at Phase III Completion"],
        [
          ["Aerobic Duration", "30-40 min/session", "40-60 min/session"],
          ["Weekly Volume", "90-150 min/week of moderate exercise", "150-300 min/week (AHA target for secondary prevention)"],
          ["Intensity", "60-75% HRR or RPE 13-14", "70-85% HRR or RPE 14-16"],
          ["Resistance Training", "2-3 sets × 12-15 reps at moderate load", "3 sets × 8-12 reps at progressive load (up to 60-70% 1RM)"],
          ["Functional Activities", "Begin return to leisure/occupational activities", "Full return to work, hobbies, sexual activity, sports"],
          ["Step Count Target", "5,000-7,000 steps/day", "8,000-10,000 steps/day (wearable-tracked)"],
        ],
        [30, 35, 35]
      ),
      spacer(),

      // PHASE 4
      phaseBox("IV", "LONG-TERM MAINTENANCE", "Independent Lifelong Exercise  |  Month 6 Onward", "145A7C"),
      spacer(),

      h3("Goals of Phase IV"),
      bullet("Maintain lifelong cardiovascular fitness and healthy lifestyle behaviors"),
      bullet("Prevent deconditioning and relapse to sedentary behavior"),
      bullet("Continue monitoring of cardiovascular risk factors"),
      bullet("Encourage participation in community-based fitness programs"),
      bullet("Annual review with cardiologist or primary care physician"),
      spacer(),

      h3("Phase IV Program Features"),
      makeTable(
        ["Aspect", "Details"],
        [
          ["Setting", "Community gym, home, recreational sports centers, walking groups"],
          ["Supervision", "Unsupervised (self-directed) with periodic medical review"],
          ["ECG Monitoring", "Not required; patient should be able to self-monitor HR and RPE"],
          ["Frequency", "≥5 days/week moderate exercise or ≥3 days/week vigorous exercise (AHA/ACC)"],
          ["Aerobic Duration", "150-300 min/week moderate intensity OR 75-150 min/week vigorous intensity"],
          ["Resistance Training", "2 days/week covering major muscle groups; progressive overload"],
          ["Flexibility & Balance", "Stretching 2-3×/week; yoga or tai chi encouraged (especially in elderly)"],
          ["Monitoring Visits", "Annual follow-up; repeat exercise stress test if indicated; lab monitoring"],
          ["Technology Support", "Wearable devices (HR monitors, pedometers, apps) may improve adherence"],
        ],
        [25, 75]
      ),
      spacer(),

      pageBreak(),

      // ─── SECTION 3: EXERCISE PROGRESSION OVERVIEW ───────────────────────────
      h1("3. EXERCISE PROGRESSION OVERVIEW ACROSS ALL PHASES"),
      spacer(),

      makeTable(
        ["Parameter", "Phase I (Inpatient)", "Phase II (Supervised Outpatient)", "Phase III (Extended Outpatient)", "Phase IV (Maintenance)"],
        [
          ["Duration", "Days 1-7 (hospital)", "12-18 weeks (36 sessions)", "3-6 months", "Lifelong"],
          ["Setting", "Hospital ward/CCU", "Cardiac rehab center", "Outpatient/community/home", "Community/home"],
          ["Supervision", "Nurse/PT continuous", "Continuous ECG monitoring", "Periodic monitoring", "Self-directed"],
          ["Exercise Type", "ROM, walking, ADLs", "Aerobic + resistance", "Aerobic + resistance + functional", "Aerobic + resistance + flexibility"],
          ["Intensity (RPE)", "Borg 9-11 (Very Light)", "Borg 11-14 (Light to Moderate)", "Borg 13-15 (Moderate to Hard)", "Borg 12-15 (Moderate)"],
          ["% HRmax or HRR", "HR rest + 20-30 bpm", "40-80% HRR (progressive)", "65-85% HRR", "60-80% HRR"],
          ["Duration/Session", "5-30 min (progressive)", "20-45 min", "30-60 min", "30-60 min"],
          ["Weekly Volume", "ADL-based", "60-150 min moderate", "150-250 min moderate", "≥150 min/week (AHA target)"],
          ["METs Target", "1-3 METs", "3-7 METs", "5-8 METs", "5-10+ METs"],
          ["ECG Monitoring", "Continuous telemetry", "Continuous each session", "Periodic/as needed", "Not required"],
        ],
        [18, 19, 21, 21, 21]
      ),
      spacer(),

      pageBreak(),

      // ─── SECTION 4: SPECIAL POPULATIONS ──────────────────────────────────────
      h1("4. CARDIAC REHABILITATION IN SPECIAL POPULATIONS"),
      spacer(),

      h2("4.1 Heart Failure with Reduced EF (HFrEF)"),
      body("Heart failure patients present unique challenges. Low baseline exercise capacity, potential for fluid shifts during exercise, and risk of decompensation require modified protocols. Multiple RCTs (HF-ACTION, SMARTEX-HF) have demonstrated benefits including improved exercise capacity and quality of life."),
      spacer(),
      makeTable(
        ["Consideration", "Recommendations for HFrEF"],
        [
          ["Initial Assessment", "Echocardiogram to confirm EF; CPET to determine safe exercise capacity; B-type natriuretic peptide (BNP) baseline"],
          ["Exercise Start Criteria", "Euvolemic state (no signs of acute decompensation); stable for ≥4 weeks on optimized GDMT (beta-blocker, ACE-I/ARB/ARNi, MRA)"],
          ["Starting Intensity", "Very low: 40-50% HRR; 2-3 METs; RPE 10-12"],
          ["Duration Progression", "Start with 10-15 min intermittent exercise; progress to 30-45 min continuous over 4-8 weeks"],
          ["Mode", "Stationary cycling preferred (constant preload/afterload); avoid isometric exercises"],
          ["HIIT in HF", "May be used in stable, well-compensated HFrEF; requires high-level supervision; evidence supports safety"],
          ["Monitoring", "Weight monitoring daily (2 kg/day gain = hold exercise; notify physician); check for edema/dyspnea before each session"],
          ["Resistance Training", "Permitted but limited: lower loads (30-40% 1RM), more repetitions; avoid Valsalva; caution in ICD/CRT device patients"],
          ["Benefit", "21-34% lower mortality in older HF patients in supervised CR (Braunwald's Heart Disease)"],
        ],
        [28, 72]
      ),
      spacer(),

      h2("4.2 Post-CABG Patients"),
      bullet("Delay upper extremity resistance training for 6-8 weeks post-sternotomy to allow sternal healing"),
      bullet("Sternal precautions: no pushing/pulling >5-10 lbs; no reaching behind back"),
      bullet("Begin ambulation as early as Day 1-2 post-op (assisted)"),
      bullet("Leg and lower body exercises can begin immediately"),
      bullet("Monitor for sternal instability (clicking, crepitus) — suspend activity and notify surgeon"),
      bullet("First Phase II session: typically 4-8 weeks post-CABG"),
      spacer(),

      h2("4.3 Post-Valve Surgery"),
      bullet("Anticoagulation management must be optimized before initiating vigorous exercise (INR therapeutic for mechanical valves)"),
      bullet("Exercise capacity may be lower than post-CABG due to pre-existing hemodynamic burden"),
      bullet("Monitor for symptoms of prosthetic valve dysfunction (dyspnea, new murmur, reduced exercise tolerance)"),
      bullet("Resistance training: proceed cautiously; avoid Valsalva maneuver with prosthetic valves"),
      spacer(),

      h2("4.4 Older Adults (≥65 Years)"),
      body("Older adults with CHD who participated in supervised CR experienced 21-34% lower mortality than nonusers over 5 years (Braunwald's). Despite this, only ~12% of Medicare-eligible patients participate in CR."),
      spacer(),
      bullet("Address frailty: use slower progression and lower initial intensities"),
      bullet("Include balance and fall-prevention training alongside aerobic and resistance exercises"),
      bullet("Home-based CR may be more accessible but requires careful safety screening"),
      bullet("Cognitive assessment to ensure safe compliance with self-monitoring"),
      bullet("Social support and transportation barriers are major participation obstacles"),
      bullet("Flexibility and stretching should be emphasized (reduced joint mobility with age)"),
      spacer(),

      h2("4.5 Women"),
      bullet("Women are significantly under-referred and under-enrolled in CR despite equal benefits"),
      bullet("May present with atypical anginal symptoms — ensure symptom recognition training"),
      bullet("Psychosocial barriers (caregiver role, depression) are more prevalent — emphasize group support"),
      bullet("Post-partum considerations if relevant (rare)"),
      spacer(),

      pageBreak(),

      // ─── SECTION 5: PSYCHOLOGICAL & NUTRITIONAL COMPONENTS ───────────────────
      h1("5. NON-EXERCISE COMPONENTS OF CARDIAC REHABILITATION"),
      spacer(),

      h2("5.1 Psychosocial Rehabilitation"),
      body("Depression and anxiety are present in 20-40% of post-MI patients and significantly worsen outcomes. CR programs address psychosocial health through structured interventions integrated into every phase."),
      spacer(),
      makeTable(
        ["Component", "Details"],
        [
          ["Screening", "PHQ-9 for depression; GAD-7 for anxiety; validated at entry and completion of Phase II"],
          ["Interventions", "Individual counseling, group therapy, cognitive behavioral therapy (CBT), stress management"],
          ["Benefits Demonstrated", "Reduced depression and anxiety scores; improved quality of life; improved social support; increased adherence to exercise and medications"],
          ["Mindfulness & Relaxation", "Progressive muscle relaxation, guided imagery, meditation — reduce cortisol and sympathetic tone"],
          ["Social Support", "Group-based CR provides peer interaction; reduces isolation; improves long-term adherence"],
          ["Sexual Activity Counseling", "Reassure patients that sexual activity is safe typically 4-6 weeks post-MI in low-risk patients (equivalent to climbing 2 flights of stairs)"],
          ["Return to Work", "Vocational counseling; typically 6-12 weeks post-MI for non-manual work; 12+ weeks for manual labor"],
        ],
        [25, 75]
      ),
      spacer(),

      h2("5.2 Nutritional Counseling"),
      makeTable(
        ["Dietary Goal", "Recommendations"],
        [
          ["Overall Pattern", "Mediterranean-style diet: fruits, vegetables, whole grains, nuts, olive oil, fish (2×/week), limited red/processed meat"],
          ["Sodium Restriction", "<2,300 mg/day (HFrEF: <1,500-2,000 mg/day)"],
          ["Saturated Fat", "<7% of total daily calories; replace with unsaturated fats"],
          ["Trans Fat", "Eliminate entirely (partially hydrogenated oils)"],
          ["Cholesterol", "<200 mg/day (particularly for hyperlipidemia)"],
          ["Omega-3 Fatty Acids", "Encourage fatty fish (salmon, mackerel); omega-3 supplementation discussed with physician"],
          ["Weight Management", "Target: BMI 20-25 kg/m²; waist circumference <102 cm (men), <88 cm (women)"],
          ["Diabetes/Glycemic Control", "Low glycemic index foods; carbohydrate monitoring; target HbA1c <7.0% with physician"],
          ["Alcohol", "Limit to ≤2 drinks/day (men); ≤1 drink/day (women); abstain in arrhythmia, HF"],
        ],
        [28, 72]
      ),
      spacer(),

      h2("5.3 Risk Factor Modification Targets"),
      makeTable(
        ["Risk Factor", "Treatment Target", "Interventions"],
        [
          ["LDL Cholesterol", "<70 mg/dL (high-risk CVD); <55 mg/dL (very high risk/recurrent events)", "High-intensity statin (atorvastatin 40-80 mg); ezetimibe; PCSK9 inhibitors if target not reached"],
          ["Blood Pressure", "<130/80 mmHg (most CVD patients)", "ACE inhibitor or ARB; beta-blocker; thiazide; dietary Na restriction; exercise"],
          ["HbA1c (Diabetes)", "<7.0% (individualized)", "Metformin; SGLT2 inhibitors (cardiorenal protection); GLP-1 agonists (CV benefit)"],
          ["BMI / Weight", "BMI <25; loss of ≥5-10% body weight if obese", "Caloric restriction, exercise, behavioral modification"],
          ["Smoking", "Complete cessation", "Varenicline, NRT (patch, gum), bupropion; behavioral counseling"],
          ["Triglycerides", "<150 mg/dL", "Omega-3 fatty acids, fibrates; limit refined carbs and alcohol"],
        ],
        [20, 25, 55]
      ),
      spacer(),

      pageBreak(),

      // ─── SECTION 6: SAFETY AND OUTCOMES ──────────────────────────────────────
      h1("6. SAFETY, OUTCOMES, AND EVIDENCE"),
      spacer(),

      h2("6.1 Safety Profile of Cardiac Rehabilitation"),
      body("Cardiac rehabilitation has an excellent safety profile. The low rate of adverse events is attributed to pre-participation screening for contraindications, individualized exercise prescription, continuous ECG monitoring, and presence of trained staff."),
      spacer(),
      makeTable(
        ["Adverse Event", "Rate", "Source"],
        [
          ["Cardiac Arrest", "1 per 116,906 patient-exercise hours", "AHA 2007 Council Report (Fuster & Hurst)"],
          ["Myocardial Infarction", "1 per 219,970 patient-exercise hours", "AHA 2007 Council Report"],
          ["Fatal Event", "1 per 752,365 patient-exercise hours", "AHA 2007 Council Report"],
          ["Cardiac Arrest (European data)", "1.3 per million patient-exercise hours", "French multicenter study"],
        ],
        [35, 35, 30]
      ),
      spacer(),

      h2("6.2 Clinical Benefits of Cardiac Rehabilitation (Evidence Summary)"),
      makeTable(
        ["Outcome", "Evidence", "Magnitude of Benefit"],
        [
          ["All-Cause Mortality", "Multiple RCTs and meta-analyses", "20-26% relative risk reduction"],
          ["Cardiovascular Mortality", "Meta-analyses of CR trials", "26-31% relative risk reduction"],
          ["Recurrent MI", "RCT data", "17-21% risk reduction"],
          ["Hospitalization", "Systematic reviews", "18-25% reduction in re-hospitalization"],
          ["Exercise Capacity (VO2 peak)", "RCTs", "+11-16% improvement in VO2 peak"],
          ["Mortality per MET increase", "Martin et al. (5,641 patients)", "13% mortality reduction per 1-MET improvement; 30% in low-fitness patients"],
          ["Quality of Life", "Standardized QoL instruments", "Clinically meaningful improvement in SF-36, MacNew scores"],
          ["Depression & Anxiety", "Multiple RCTs", "Significant reduction in PHQ-9 and GAD-7 scores"],
          ["HF-specific: Mortality (older adults)", "Braunwald's Heart Disease", "21-34% lower mortality vs. non-participants over 5 years"],
        ],
        [28, 35, 37]
      ),
      spacer(),

      h2("6.3 Exercise Non-Responders"),
      body("A clinically important subset of CR patients (~21-23%) fail to show any improvement in VO2 peak after completing Phase II. This non-response is associated with worse long-term outcomes (3x higher mortality than high responders at 6.4 years - De Schutter et al.)."),
      spacer(),
      bullet("Non-responders should be identified early using VO2 peak measurement before and after Phase II"),
      bullet("Increasing exercise volume AND intensity (high volume/high intensity) eliminates non-response (Ross et al.)"),
      bullet("HIIT protocols may be offered to non-responders in clinically appropriate patients"),
      bullet("Other contributing factors to non-response: poor adherence, subtherapeutic beta-blockade, underlying anemia, sleep apnea"),
      spacer(),

      pageBreak(),

      // ─── SECTION 7: HOME-BASED AND DIGITAL CR ─────────────────────────────────
      h1("7. HOME-BASED AND DIGITAL CARDIAC REHABILITATION"),
      spacer(),
      body("Home-based CR programs have gained momentum, particularly post-COVID, due to accessibility, cost, and patient preference. While center-based programs remain the gold standard for high-risk patients requiring continuous monitoring, home-based programs show equivalent benefits for low-to-moderate risk patients."),
      spacer(),
      makeTable(
        ["Feature", "Center-Based CR", "Home-Based CR"],
        [
          ["Supervision", "In-person, direct supervision with continuous ECG", "Remote (phone, video, app-based) supervision"],
          ["ECG Monitoring", "Continuous telemetry", "Wearable ECG devices (e.g., Kardia, Holter)"],
          ["Risk Stratification Requirement", "All risk levels (high risk requires center)", "Low to moderate risk only"],
          ["Patient Population", "All phases, including high-risk", "Phase II (low/moderate risk), Phase III, Phase IV"],
          ["Cost", "Higher (facility, staff)", "Lower for patient and health system"],
          ["Participation Rate", "Limited by travel, schedule, geography", "Higher potential participation (elderly, rural, working patients)"],
          ["Evidence", "Gold standard — extensive RCT evidence", "Growing evidence of equivalence in low-risk patients (CROS, HEART studies)"],
          ["Technology", "Exercise equipment, ECG lab, dietitian", "Wearables, smartphone apps, telemedicine platforms"],
          ["Educational Delivery", "In-person group/individual sessions", "Digital platforms, apps, video calls"],
        ],
        [25, 37, 38]
      ),
      spacer(),

      // ─── SECTION 8: QUICK REFERENCE ──────────────────────────────────────────
      h1("8. QUICK REFERENCE GUIDE — EXERCISE PARAMETERS"),
      spacer(),

      h2("8.1 Borg Rate of Perceived Exertion (RPE) Scale"),
      makeTable(
        ["Score", "Description", "CR Phase Application"],
        [
          ["6", "No exertion at all", "—"],
          ["7-8", "Extremely light", "Phase I Day 1-2 only"],
          ["9-10", "Very light", "Phase I (general)"],
          ["11-12", "Light", "Phase I — Phase II Early (Weeks 1-3)"],
          ["13-14", "Somewhat hard (moderate)", "Phase II Mid-to-Late; Phase III target"],
          ["15-16", "Hard (vigorous)", "Phase III-IV advanced; HIIT sessions"],
          ["17-18", "Very hard", "HIIT peak intervals only (selected patients)"],
          ["19-20", "Maximal exertion", "Avoided in CR (except symptom-limited ETT)"],
        ],
        [10, 28, 62]
      ),
      spacer(),

      h2("8.2 MET Reference Table for Common Activities"),
      makeTable(
        ["Activity", "Approximate METs", "CR Phase"],
        [
          ["Resting / Sleeping", "1.0 MET", "—"],
          ["Dressing, personal care", "1.5-2.0 METs", "Phase I"],
          ["Slow walking (1.5 mph)", "2.0 METs", "Phase I"],
          ["Walking on level (2.5 mph)", "2.5-3.0 METs", "Phase I late / Phase II early"],
          ["Stationary cycling (light effort)", "3.0-4.0 METs", "Phase II"],
          ["Walking briskly (3.5 mph)", "4.0-5.0 METs", "Phase II mid"],
          ["Swimming (moderate)", "5.0-6.0 METs", "Phase II-III"],
          ["Cycling outdoors (moderate)", "6.0-8.0 METs", "Phase III-IV"],
          ["Jogging (5 mph)", "8.0 METs", "Phase III-IV (selected)"],
          ["Running (7 mph)", "11.0 METs", "Phase IV (elite patients only)"],
          ["Sexual activity (moderate effort)", "3.0-5.0 METs", "Safe from Phase II (4-6 weeks post-event)"],
          ["Driving a car", "2.0-3.0 METs", "Safe from 4-6 weeks post-MI (check local rules)"],
        ],
        [35, 25, 40]
      ),
      spacer(),

      // ─── REFERENCES ───────────────────────────────────────────────────────────
      h1("REFERENCES"),
      spacer(),
      bullet("Rozanski A, Setareh-Shenas S, Narula J. Cardiac Rehabilitation: Current Practice and Future Directions. In: Fuster and Hurst's The Heart, 15th Edition. McGraw-Hill, 2022."),
      bullet("Braunwald E, et al. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 12th Edition. Elsevier, 2022. Chapter 33: Cardiac Rehabilitation."),
      bullet("Thomas RJ, et al. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, American Heart Association. Circulation. 2019;140:e69-e89."),
      bullet("Kachur S, et al. Cardiac Rehabilitation. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. PMID: NBK537196."),
      bullet("Balady GJ, et al. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update. Circulation. 2007;115:2675-2682."),
      bullet("Piepoli MF, et al. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. Eur Heart J. 2010;31(16):1967-1976."),
      bullet("WHO Rehabilitation Guideline after Myocardial Infarction. 2011. WHO Western Pacific Region Guidelines."),
      bullet("Martin BJ, et al. Improvement in exercise capacity following cardiac rehabilitation predicts cardiovascular risk. Am J Cardiol. 2013;112:1235-1240. (5,641-patient study: 13% mortality per 1-MET increase)"),
      bullet("De Schutter A, et al. Nonresponse in cardiorespiratory fitness and its predictors in cardiac rehabilitation. Am J Cardiol. 2021. (23% non-responders; 3x mortality in nonresponders vs. high responders)"),
      bullet("Ross R, et al. Dose-Response Effects of Exercise on Cardiorespiratory Fitness among Sedentary Obese Adults. Am J Physiol Heart Circ Physiol. 2015. (High volume/high intensity eliminated non-response)"),
      spacer(),

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// ─── 200 MCQs ─────────────────────────────────────────────────────────────────
// Format: { q, o:[A,B,C,D], a:'A'|'B'|'C'|'D', section }
const mcqs = [

// ══════════════════════════════════════════════════════════════════
// SECTION 1: OVERVIEW OF CARDIAC REHABILITATION (Q1-25)
// ══════════════════════════════════════════════════════════════════
{ q:"1. Which of the following BEST defines cardiac rehabilitation (CR)?",
  o:["A. A surgical procedure to bypass blocked coronary arteries",
     "B. A multidisciplinary secondary prevention program combining exercise training, risk factor modification, and education",
     "C. A pharmacological regimen exclusively targeting lipid reduction",
     "D. An inpatient program restricted to post-MI patients only"],
  a:"B", section:"Overview" },

{ q:"2. In the early 20th century, myocardial infarction was treated with how many weeks of strict bedrest?",
  o:["A. 1-2 weeks","B. 3-4 weeks","C. 6-8 weeks","D. 10-12 weeks"],
  a:"C", section:"Overview" },

{ q:"3. Which physicians first advocated for early 'armchair' ambulation within 1 day of acute MI in the early 1950s?",
  o:["A. Braunwald and Hurst","B. Levine and Lown","C. Hellerstein and Morris","D. Wenger and DeBakey"],
  a:"B", section:"Overview" },

{ q:"4. How many core competencies are recognized in modern cardiac rehabilitation?",
  o:["A. Three","B. Four","C. Five","D. Six"],
  a:"C", section:"Overview" },

{ q:"5. Which of the following is NOT one of the five core competencies of cardiac rehabilitation?",
  o:["A. Dietary counseling","B. Psychosocial interventions","C. Surgical coronary revascularization","D. Risk factor modification"],
  a:"C", section:"Overview" },

{ q:"6. The standard US/Canada cardiac rehabilitation program consists of how many outpatient sessions?",
  o:["A. 12 sessions","B. 24 sessions","C. 36 sessions","D. 48 sessions"],
  a:"C", section:"Overview" },

{ q:"7. Cardiac rehabilitation sessions are typically delivered at what frequency per week?",
  o:["A. Daily (7 days/week)","B. 2-3 sessions per week","C. 5 sessions per week only","D. Once weekly"],
  a:"B", section:"Overview" },

{ q:"8. The American Heart Association formally recognized CR as a comprehensive secondary risk factor modification program in which year?",
  o:["A. 1975","B. 1985","C. 1994","D. 2007"],
  a:"C", section:"Overview" },

{ q:"9. Which of the following is a Medicare-approved indication for cardiac rehabilitation added in 2014?",
  o:["A. Stable angina pectoris",
     "B. Heart failure with reduced ejection fraction (HFrEF)",
     "C. Peripheral arterial disease",
     "D. Type 2 diabetes mellitus"],
  a:"B", section:"Overview" },

{ q:"10. According to ACC/AHA 2018 updates, which patient is eligible for cardiac rehabilitation?",
  o:["A. Patient with asymptomatic hypertension only",
     "B. Patient post-percutaneous coronary intervention (PCI)",
     "C. Patient with heart failure with preserved ejection fraction (HFpEF)",
     "D. Patient with asymptomatic mild aortic regurgitation"],
  a:"B", section:"Overview" },

{ q:"11. Which contraindication to cardiac rehabilitation is listed in Fuster & Hurst's The Heart, 15th Edition?",
  o:["A. Controlled hypertension on medication",
     "B. History of DVT more than 6 months ago",
     "C. Decompensated heart failure",
     "D. Mild stable angina"],
  a:"C", section:"Overview" },

{ q:"12. A patient with severe symptomatic aortic stenosis wishes to enroll in cardiac rehabilitation. What is the correct approach?",
  o:["A. Enroll immediately with low-intensity exercise",
     "B. Contraindicated — defer until valve intervention",
     "C. Enroll with continuous ECG monitoring only",
     "D. Enroll but avoid resistance training only"],
  a:"B", section:"Overview" },

{ q:"13. Cardiac rehabilitation is contraindicated in which of the following arrhythmia situations?",
  o:["A. Well-controlled atrial fibrillation with resting HR 72 bpm",
     "B. Atrial arrhythmia with uncontrolled ventricular response",
     "C. Occasional isolated PVCs at rest",
     "D. Sinus bradycardia HR 55 bpm on beta-blocker"],
  a:"B", section:"Overview" },

{ q:"14. Which format of cardiac rehabilitation has the highest worldwide median sessions?",
  o:["A. Home-based programs (median 6 sessions)",
     "B. Telemedicine-only programs",
     "C. Center-based supervised programs (median 24 sessions)",
     "D. Hospital inpatient programs"],
  a:"C", section:"Overview" },

{ q:"15. During Phase II cardiac rehabilitation exercise sessions, which monitoring is routinely performed?",
  o:["A. Continuous pulse oximetry only",
     "B. Continuous blood glucose monitoring",
     "C. Continuous ECG telemetry",
     "D. Intermittent echocardiography"],
  a:"C", section:"Overview" },

{ q:"16. Which of the following represents a correct statement about the history of outpatient cardiac rehabilitation?",
  o:["A. Outpatient programs began in the 1940s before inpatient programs",
     "B. Hellerstein described benefits of exercise training for cardiac patients in the late 1960s",
     "C. Outpatient CR became common before the 1960s",
     "D. The AHA first endorsed CR in the 1970s"],
  a:"B", section:"Overview" },

{ q:"17. A patient post-cardiac transplantation wishes to enroll in CR. This is:",
  o:["A. Absolutely contraindicated","B. An eligible indication for CR","C. Only permitted in Phase IV","D. Only indicated if EF <40%"],
  a:"B", section:"Overview" },

{ q:"18. Cardiac rehabilitation is indicated for patients with peripheral vascular disease primarily to:",
  o:["A. Treat intermittent claudication and improve walking tolerance",
     "B. Prevent sternal wound infection",
     "C. Reduce post-operative DVT risk only",
     "D. Manage atrial fibrillation"],
  a:"A", section:"Overview" },

{ q:"19. Which statement about Phase 3 (maintenance) cardiac rehabilitation is CORRECT?",
  o:["A. Phase 3 requires continuous ECG monitoring like Phase 2",
     "B. Phase 3 programs are mandatory for all CR patients in the US",
     "C. Phase 3 may or may not be medically supervised and generally does not include ECG monitoring",
     "D. Phase 3 consists of 36 additional sessions"],
  a:"C", section:"Overview" },

{ q:"20. A patient has complex ventricular arrhythmia on resting ECG. Enrolling them in Phase II CR is:",
  o:["A. Acceptable with modified low-intensity protocol",
     "B. Contraindicated per AHA/ACC guidelines",
     "C. Acceptable with antiarrhythmic drug coverage only",
     "D. Only contraindicated during resistance training"],
  a:"B", section:"Overview" },

{ q:"21. Which of the following statements about intracavitary thrombus and CR is correct?",
  o:["A. It is a relative contraindication only",
     "B. It is an absolute contraindication to starting CR exercise",
     "C. It only contraindicates resistance training",
     "D. CR can start after anticoagulation for 48 hours"],
  a:"B", section:"Overview" },

{ q:"22. The 'teachable moment' in Phase I cardiac rehabilitation refers to:",
  o:["A. The time after exercise when the patient is most receptive to physiotherapy",
     "B. Using the patient's hospitalization and vulnerability to instruct them on risk factor modification",
     "C. The period just before discharge when medications are reviewed",
     "D. The first Phase II session when education begins"],
  a:"B", section:"Overview" },

{ q:"23. Severe obstructive cardiomyopathy (HOCM) is a contraindication to CR because:",
  o:["A. It causes resting hypotension",
     "B. Dynamic LVOT obstruction worsens with exertion, increasing sudden death risk",
     "C. Patients have impaired renal function",
     "D. It is associated with pulmonary fibrosis"],
  a:"B", section:"Overview" },

{ q:"24. Which diet is recommended in cardiac rehabilitation for secondary prevention?",
  o:["A. High-protein, low-carbohydrate (ketogenic) diet",
     "B. DASH diet only",
     "C. Mediterranean-style diet (fruits, vegetables, whole grains, fish, olive oil)",
     "D. Very-low-fat diet (<10% calories from fat)"],
  a:"C", section:"Overview" },

{ q:"25. The worldwide median duration of home-based cardiac rehabilitation is approximately:",
  o:["A. 6 sessions","B. 12 sessions","C. 24 sessions","D. 36 sessions"],
  a:"A", section:"Overview" },

// ══════════════════════════════════════════════════════════════════
// SECTION 2: PHASE I — INPATIENT (Q26-55)
// ══════════════════════════════════════════════════════════════════
{ q:"26. Phase I cardiac rehabilitation takes place in which setting?",
  o:["A. Community gymnasium","B. Outpatient physiotherapy clinic","C. Hospital ward or CCU during acute admission","D. Patient's home"],
  a:"C", section:"Phase I" },

{ q:"27. What is the PRIMARY goal of Phase I cardiac rehabilitation?",
  o:["A. Achieve maximum VO2 peak improvement",
     "B. Enable safe hospital discharge and prevent complications of bedrest",
     "C. Begin high-intensity interval training",
     "D. Complete 36 supervised exercise sessions"],
  a:"B", section:"Phase I" },

{ q:"28. On Day 1 of Phase I (ICU/CCU), which exercise is most appropriate?",
  o:["A. Treadmill walking at 3 METs",
     "B. Passive range of motion, leg exercises in bed, and deep breathing exercises",
     "C. Stationary cycling at moderate intensity",
     "D. Resistance training with light weights"],
  a:"B", section:"Phase I" },

{ q:"29. Which of the following is NOT a goal of Phase I cardiac rehabilitation?",
  o:["A. Preventing DVT","B. Preventing atelectasis","C. Achieving 6-8 METs of exercise capacity","D. Educating the patient about their cardiac condition"],
  a:"C", section:"Phase I" },

{ q:"30. In Phase I, what is the maximum recommended heart rate increase above resting during exercise?",
  o:["A. 10-15 bpm","B. 20-30 bpm","C. 40-50 bpm","D. 60-70 bpm"],
  a:"B", section:"Phase I" },

{ q:"31. According to Phase I protocols, at what HR should exercise be stopped post-MI?",
  o:["A. HR >100 bpm","B. HR >120 bpm","C. HR >150 bpm","D. HR >180 bpm"],
  a:"B", section:"Phase I" },

{ q:"32. The target Borg RPE during Phase I exercise is:",
  o:["A. 6-8 (no exertion to extremely light)","B. 9-11 (very light to light)","C. 14-16 (hard to very hard)","D. 17-19 (very hard to extremely hard)"],
  a:"B", section:"Phase I" },

{ q:"33. During Phase I exercise, SpO2 falls to 88%. The correct response is:",
  o:["A. Continue exercise but reduce intensity by 20%",
     "B. Suspend activity immediately",
     "C. Apply supplemental oxygen and continue",
     "D. Continue exercise and recheck in 5 minutes"],
  a:"B", section:"Phase I" },

{ q:"34. By Day 6-7 (pre-discharge) in Phase I, a patient should ideally be able to walk approximately:",
  o:["A. 50-100 meters","B. 100-200 meters","C. 200-400 meters","D. 500-1000 meters"],
  a:"C", section:"Phase I" },

{ q:"35. Which monitoring is used during Phase I activities?",
  o:["A. No monitoring required for light activities",
     "B. Continuous ECG telemetry and BP before/after activities",
     "C. Echocardiography during each activity",
     "D. Cardiac MRI after each session"],
  a:"B", section:"Phase I" },

{ q:"36. When should a post-MI patient in hospital be mobilized to a chair according to Phase I protocols?",
  o:["A. After 48 hours regardless of blood pressure",
     "B. Only after 5 days post-MI",
     "C. As soon as the stroke/event is completed and blood pressure is stable",
     "D. Only after echocardiography confirms EF >50%"],
  a:"C", section:"Phase I" },

{ q:"37. Phase I education does NOT typically include:",
  o:["A. Explanation of medications including beta-blockers and statins",
     "B. Warning signs requiring emergency attention",
     "C. High-intensity interval training techniques",
     "D. Wound care instructions for sternotomy site"],
  a:"C", section:"Phase I" },

{ q:"38. During Phase I, what systolic blood pressure rise during exercise should prompt stopping?",
  o:["A. SBP rise >10 mmHg","B. SBP rise >20 mmHg","C. SBP rise >40 mmHg","D. SBP rise >80 mmHg"],
  a:"C", section:"Phase I" },

{ q:"39. A patient on Day 2 of Phase I post-CABG has a sternal click with ambulation. What should be done?",
  o:["A. Continue ambulation but avoid upper body movements",
     "B. Reduce exercise intensity to 1 MET only",
     "C. Suspend activity and notify the surgeon regarding possible sternal instability",
     "D. Apply a chest binder and continue Phase I as planned"],
  a:"C", section:"Phase I" },

{ q:"40. Which of the following complications of prolonged bedrest does Phase I aim to PREVENT?",
  o:["A. Aortic dissection","B. Pulmonary embolism and DVT","C. Myocardial re-infarction","D. Contrast nephropathy"],
  a:"B", section:"Phase I" },

{ q:"41. In Phase I, stair climbing supervision typically begins on which day?",
  o:["A. Day 1-2","B. Day 3-5","C. Day 4-5","D. Day 1 only"],
  a:"C", section:"Phase I" },

{ q:"42. Phase I activities are measured in METs. Resting/personal care activities correspond to approximately:",
  o:["A. 1.0-1.5 METs","B. 3.0-4.0 METs","C. 5.0-6.0 METs","D. 7.0-8.0 METs"],
  a:"A", section:"Phase I" },

{ q:"43. Which statement about Phase I cardiac rehabilitation in the United States is CORRECT?",
  o:["A. Phase I programs are expanding due to longer hospital stays",
     "B. Formal Phase I programs have largely devolved due to the short duration of hospital stays",
     "C. Phase I is now 14 days in most US hospitals",
     "D. Phase I is no longer part of CR guidelines"],
  a:"B", section:"Phase I" },

{ q:"44. What is the maximum MET level targeted during Phase I?",
  o:["A. 1-3 METs","B. 4-6 METs","C. 7-9 METs","D. 10-12 METs"],
  a:"A", section:"Phase I" },

{ q:"45. Passive range of motion exercises during Phase I are performed primarily to prevent:",
  o:["A. Myocardial rupture","B. Contractures and joint capsulitis","C. Pulmonary edema","D. Arrhythmias"],
  a:"B", section:"Phase I" },

{ q:"46. Which of the following is a Phase I education topic regarding activity after MI?",
  o:["A. Supervised HIIT protocols for home use",
     "B. Safe return to driving and sexual activity timelines",
     "C. Advanced cardiac life support self-training",
     "D. Implanting a loop recorder"],
  a:"B", section:"Phase I" },

{ q:"47. A DBP rise of >20 mmHg during Phase I exercise should prompt:",
  o:["A. Continuing exercise at the same intensity",
     "B. Stopping exercise immediately",
     "C. Giving sublingual nitrate and continuing",
     "D. Increasing the exercise intensity"],
  a:"B", section:"Phase I" },

{ q:"48. Post-CABG Phase I exercise for the lower extremities may begin:",
  o:["A. Only after sternal healing at 8 weeks",
     "B. Only after pulmonary function normalizes",
     "C. Immediately post-operatively (Day 1-2)",
     "D. After 4 weeks post-surgery"],
  a:"C", section:"Phase I" },

{ q:"49. A patient completes Phase I and is being discharged. What should be provided?",
  o:["A. A prescription for home HIIT training",
     "B. A safe, limited home exercise plan and enrollment in Phase II",
     "C. Clearance for immediate return to all previous activities",
     "D. Instructions to avoid all physical activity for 6 weeks"],
  a:"B", section:"Phase I" },

{ q:"50. Which breathing exercise is appropriate for Phase I Day 1?",
  o:["A. High-resistance inspiratory muscle training","B. Spirometry challenge at maximal effort","C. Diaphragmatic and deep breathing exercises","D. Pursed-lip breathing at 6 METs"],
  a:"C", section:"Phase I" },

{ q:"51. The Phase I 'bridge' function refers to:",
  o:["A. Bridging anticoagulation for valve surgery",
     "B. Creating continuity of care between hospital admission and outpatient Phase II enrollment",
     "C. A physical bridge exercise for hip strengthening",
     "D. Connecting the patient's GP with the cardiologist"],
  a:"B", section:"Phase I" },

{ q:"52. Active-assisted ROM exercises typically begin on which day of Phase I?",
  o:["A. Day 1","B. Day 2","C. Day 5","D. Day 7"],
  a:"B", section:"Phase I" },

{ q:"53. A Phase I patient reports RPE of 16 during corridor ambulation. The appropriate response is:",
  o:["A. Encourage the patient — this is the target RPE",
     "B. Reduce intensity or stop and reassess",
     "C. Progress to stair climbing immediately",
     "D. Add resistance training to the session"],
  a:"B", section:"Phase I" },

{ q:"54. The primary reason ambulation is initiated during Phase I (not bedrest) is:",
  o:["A. To prepare for HIIT in Phase II",
     "B. To reduce hospital costs by shortening stay",
     "C. Because early ambulation is both safe and reduces morbidity post-MI",
     "D. Because bedrest has no cardiovascular risks"],
  a:"C", section:"Phase I" },

{ q:"55. During Phase I, how often should blood pressure be monitored during early mobilization?",
  o:["A. Only at the start of the session",
     "B. Every 15 minutes during ICU/CCU exercise and before/after all activities",
     "C. Once daily in the morning only",
     "D. Only if patient reports symptoms"],
  a:"B", section:"Phase I" },

// ══════════════════════════════════════════════════════════════════
// SECTION 3: PHASE II — SUPERVISED OUTPATIENT (Q56-100)
// ══════════════════════════════════════════════════════════════════
{ q:"56. Phase II cardiac rehabilitation typically lasts how long?",
  o:["A. 2-4 weeks","B. 6-8 weeks","C. 12-18 weeks (36 sessions)","D. 6 months continuously"],
  a:"C", section:"Phase II" },

{ q:"57. Prior to initiating Phase II, which assessment is most informative for exercise prescription?",
  o:["A. Chest X-ray","B. Cardiopulmonary exercise test (CPET) or exercise tolerance test (ETT)","C. Resting echocardiography only","D. Serum BNP level"],
  a:"B", section:"Phase II" },

{ q:"58. A patient on beta-blockers enters Phase II. Which intensity-monitoring method is MOST reliable?",
  o:["A. Percentage of age-predicted maximum HR (220-age)",
     "B. Borg Rate of Perceived Exertion (RPE) scale (target 12-14)",
     "C. Maximum heart rate formula (220 - age × 0.85)",
     "D. Resting heart rate alone"],
  a:"B", section:"Phase II" },

{ q:"59. The Karvonen formula for training heart rate is:",
  o:["A. THR = HRmax × 0.70",
     "B. THR = [(HRmax - HRrest) × target%] + HRrest",
     "C. THR = HRrest + 20 bpm",
     "D. THR = (HRmax + HRrest) / 2"],
  a:"B", section:"Phase II" },

{ q:"60. In Phase II, the target heart rate reserve (HRR) range for mid-program (Weeks 4-8) is:",
  o:["A. 20-40% HRR","B. 40-60% HRR","C. 50-70% HRR","D. 80-90% HRR"],
  a:"C", section:"Phase II" },

{ q:"61. What Borg RPE range is targeted during Phase II aerobic exercise (moderate intensity)?",
  o:["A. 6-8 (no exertion)","B. 9-11 (very light)","C. 12-14 (somewhat hard)","D. 17-19 (very hard)"],
  a:"C", section:"Phase II" },

{ q:"62. The AHA risk stratification for cardiac rehabilitation classifies a patient with EF <40% and complex arrhythmias as:",
  o:["A. Low risk","B. Moderate risk","C. High risk","D. Not eligible for CR"],
  a:"C", section:"Phase II" },

{ q:"63. A low-risk Phase II patient requires ECG monitoring for approximately how many sessions?",
  o:["A. All 36 sessions","B. First 6-12 sessions, then periodic","C. First 2 sessions only","D. No ECG monitoring required"],
  a:"B", section:"Phase II" },

{ q:"64. Resistance training in Phase II is typically added after how many weeks of aerobic conditioning?",
  o:["A. Immediately from session 1","B. After 2-4 weeks of aerobic conditioning","C. After 8-10 weeks","D. After completion of all 36 aerobic sessions"],
  a:"B", section:"Phase II" },

{ q:"65. Post-sternotomy patients should avoid upper extremity resistance training for approximately:",
  o:["A. 2 weeks","B. 4 weeks","C. 6-8 weeks","D. 12 weeks"],
  a:"C", section:"Phase II" },

{ q:"66. The recommended starting load for upper body resistance training in Phase II is:",
  o:["A. 60-70% of 1RM","B. 30-40% of 1RM","C. 80% of 1RM","D. 100% bodyweight"],
  a:"B", section:"Phase II" },

{ q:"67. Resistance training load should be progressed when the patient can complete 15 repetitions:",
  o:["A. Once in a single session",
     "B. With good form over 2 consecutive sessions",
     "C. After the first week regardless of form",
     "D. Whenever the patient requests an increase"],
  a:"B", section:"Phase II" },

{ q:"68. During Phase II, the warm-up component should last approximately:",
  o:["A. 1-2 minutes","B. 5-10 minutes","C. 15-20 minutes","D. 30 minutes"],
  a:"B", section:"Phase II" },

{ q:"69. The primary purpose of the cool-down in a Phase II session is:",
  o:["A. Increase heart rate to maximum before ending the session",
     "B. Prevent post-exercise hypotension, arrhythmias, and promote venous return",
     "C. Begin resistance training at high loads",
     "D. Perform maximal sprint intervals"],
  a:"B", section:"Phase II" },

{ q:"70. A patient in Phase II exercises and has SBP drop of 15 mmHg during increasing workload. This indicates:",
  o:["A. Normal hypotensive response — continue exercise",
     "B. Hemodynamic instability — stop exercise and notify physician",
     "C. Successful beta-blockade — reduce exercise intensity",
     "D. Over-hydration — restrict fluids and continue"],
  a:"B", section:"Phase II" },

{ q:"71. During Phase II, the aerobic training duration target by end of program (Weeks 9-12) is:",
  o:["A. 10-15 minutes","B. 15-20 minutes","C. 30-45 minutes","D. 60-90 minutes"],
  a:"C", section:"Phase II" },

{ q:"72. The starting aerobic exercise duration in Phase II (Weeks 1-3) should be approximately:",
  o:["A. 5-10 minutes","B. 15-20 minutes","C. 30-40 minutes","D. 45-60 minutes"],
  a:"B", section:"Phase II" },

{ q:"73. High-intensity interval training (HIIT) in Phase II consists of:",
  o:["A. Continuous moderate exercise at 65% HRmax throughout the session",
     "B. Repeated bouts of high-intensity exercise (85-95% HRmax) alternating with low-intensity recovery",
     "C. Resistance training only at maximum loads",
     "D. Walking at 40% HRmax for 60 minutes"],
  a:"B", section:"Phase II" },

{ q:"74. Research by Ross et al. demonstrated that exercise non-response was completely eliminated in which group?",
  o:["A. Low volume, low intensity (50% VO2 peak)",
     "B. High volume, low intensity (50% VO2 peak)",
     "C. High volume, high intensity (75% VO2 peak)",
     "D. Low volume, high intensity (75% VO2 peak)"],
  a:"C", section:"Phase II" },

{ q:"75. According to Martin et al. (5,641 patients), each 1-MET improvement in exercise capacity is associated with what reduction in mortality risk?",
  o:["A. 5%","B. 8%","C. 13%","D. 25%"],
  a:"C", section:"Phase II" },

{ q:"76. De Schutter et al. found that non-responders to CR exercise training had what mortality risk compared to high responders?",
  o:["A. Equal mortality","B. 1.5x higher mortality","C. 2x higher mortality","D. 3x higher mortality"],
  a:"D", section:"Phase II" },

{ q:"77. What percentage of CR patients are typically exercise non-responders (no improvement in VO2 peak)?",
  o:["A. 2-5%","B. 10-15%","C. 21-23%","D. 40-50%"],
  a:"C", section:"Phase II" },

{ q:"78. The 'Talk Test' is used during Phase II to assess:",
  o:["A. Cognitive function and dementia screening",
     "B. Moderate exercise intensity (patient should speak in short sentences)",
     "C. Dysphagia and swallowing function",
     "D. Cardiac output response to exercise"],
  a:"B", section:"Phase II" },

{ q:"79. In patients with chronotropic incompetence on beta-blockers, the preferred exercise intensity guide is:",
  o:["A. 220 - age × 0.85","B. Direct HRmax measurement","C. Borg RPE scale (target 12-14)","D. SBP response during exercise"],
  a:"C", section:"Phase II" },

{ q:"80. The 'somewhat hard' rating on the Borg RPE scale corresponds to:",
  o:["A. Borg 9-10","B. Borg 11-12","C. Borg 13-14","D. Borg 15-16"],
  a:"C", section:"Phase II" },

{ q:"81. The recommended starting lower body resistance training load in Phase II is:",
  o:["A. 20-30% of 1RM","B. 50-60% of 1RM","C. 70-80% of 1RM","D. 90% of 1RM"],
  a:"B", section:"Phase II" },

{ q:"82. How many sets of resistance exercises are typically prescribed in Phase II?",
  o:["A. 5-7 sets","B. 4-5 sets","C. 1-3 sets of 10-15 repetitions","D. 8-10 sets at maximum load"],
  a:"C", section:"Phase II" },

{ q:"83. Which ECG change during Phase II exercise should prompt immediate cessation?",
  o:["A. Sinus tachycardia at 120 bpm",
     "B. ST depression >2 mm or new ST elevation",
     "C. QTc of 420 ms",
     "D. Sinus arrhythmia during breathing"],
  a:"B", section:"Phase II" },

{ q:"84. A Phase II patient develops pallor and diaphoresis during cycling at moderate intensity. The correct action is:",
  o:["A. Continue exercise — this is normal exertional response",
     "B. Stop exercise immediately, assess vital signs, notify physician",
     "C. Increase exercise intensity to push through symptoms",
     "D. Administer sublingual nitrate and continue"],
  a:"B", section:"Phase II" },

{ q:"85. Which psychosocial screening tool is recommended at entry and completion of Phase II?",
  o:["A. Mini-Mental State Examination (MMSE)",
     "B. Montreal Cognitive Assessment (MoCA)",
     "C. PHQ-9 (depression) and GAD-7 (anxiety)",
     "D. AUDIT alcohol screening tool"],
  a:"C", section:"Phase II" },

{ q:"86. The AHA reported the rate of MI during supervised Phase II exercise as approximately:",
  o:["A. 1 per 10,000 patient-hours",
     "B. 1 per 50,000 patient-hours",
     "C. 1 per 219,970 patient-hours",
     "D. 1 per 1,000,000 patient-hours"],
  a:"C", section:"Phase II" },

{ q:"87. The AHA reported the rate of fatal events during Phase II exercise as approximately:",
  o:["A. 1 per 116,906 patient-hours",
     "B. 1 per 219,970 patient-hours",
     "C. 1 per 752,365 patient-hours",
     "D. 1 per 2,000,000 patient-hours"],
  a:"C", section:"Phase II" },

{ q:"88. Which of the following is the MOST common exercise modality in Phase II?",
  o:["A. Swimming and aquatic therapy",
     "B. Treadmill walking and stationary cycling",
     "C. Heavy resistance training only",
     "D. Yoga and stretching exclusively"],
  a:"B", section:"Phase II" },

{ q:"89. Which of the following represents a moderate-risk patient for Phase II CR?",
  o:["A. EF >50%, no angina, >6 METs capacity",
     "B. EF 40-49%, mild-moderate angina, ST depression 1-2 mm",
     "C. EF <40%, complex arrhythmias, prior cardiac arrest",
     "D. Asymptomatic patient with 1 vessel CAD and preserved EF"],
  a:"B", section:"Phase II" },

{ q:"90. HIIT is MOST appropriately offered to which Phase II patient?",
  o:["A. Patient with EF 25%, complex VT, and frailty",
     "B. Clinically stable, low-to-moderate risk, EF >45%, baseline capacity ≥4 METs, no complex arrhythmias",
     "C. Patient 1 week post-STEMI with ongoing chest pain",
     "D. Patient with decompensated HF and peripheral edema"],
  a:"B", section:"Phase II" },

{ q:"91. A Phase II patient's resting HR is 68 bpm and peak HR on ETT is 148 bpm. Using Karvonen at 70% HRR, the training HR is:",
  o:["A. 96 bpm","B. 112 bpm","C. 124 bpm","D. 136 bpm"],
  a:"C", section:"Phase II" },

{ q:"92. A 4×4 HIIT protocol involves high-intensity intervals at what percentage of HRmax?",
  o:["A. 50-60% HRmax","B. 65-70% HRmax","C. 85-95% HRmax","D. 100% HRmax (VO2 max)"],
  a:"C", section:"Phase II" },

{ q:"93. An education session in Phase II addressing LDL target for high-risk CVD patients should state the target is:",
  o:["A. <100 mg/dL","B. <70 mg/dL","C. <130 mg/dL","D. <55 mg/dL for all CVD patients"],
  a:"B", section:"Phase II" },

{ q:"94. The blood pressure target addressed during Phase II risk factor modification is:",
  o:["A. <140/90 mmHg (all CVD patients)","B. <130/80 mmHg","C. <120/80 mmHg only","D. <150/90 mmHg in elderly"],
  a:"B", section:"Phase II" },

{ q:"95. Sexual activity counseling in Phase II: when is it generally safe to resume for low-risk post-MI patients?",
  o:["A. After 1 week",
     "B. After 4-6 weeks post-MI (equivalent to climbing 2 flights of stairs)",
     "C. After completing all 36 Phase II sessions",
     "D. Only after Phase III completion"],
  a:"B", section:"Phase II" },

{ q:"96. Return to non-manual work post-MI is typically expected at:",
  o:["A. 1-2 weeks","B. 2-4 weeks","C. 6-12 weeks","D. 6 months minimum"],
  a:"C", section:"Phase II" },

{ q:"97. In Phase II, resistance exercises are performed on how many days per week?",
  o:["A. Daily (7 days/week)","B. 2-3 non-consecutive days/week","C. 5 consecutive days/week","D. Once per week only"],
  a:"B", section:"Phase II" },

{ q:"98. A patient progresses resistance load by 5% when they can complete 15 reps with good form over how many consecutive sessions?",
  o:["A. 1 session","B. 2 consecutive sessions","C. 5 consecutive sessions","D. 10 consecutive sessions"],
  a:"B", section:"Phase II" },

{ q:"99. What is the approximate MET target for Phase II mid-program exercise?",
  o:["A. 1-2 METs","B. 2-3 METs","C. 4-6 METs","D. 8-10 METs"],
  a:"C", section:"Phase II" },

{ q:"100. The 'pre-exercise' contraindication screening before each Phase II session includes checking for:",
  o:["A. Patient's insurance status and number of remaining sessions",
     "B. New symptoms, chest pain, dyspnea at rest, and BP/HR instability",
     "C. Serum troponin and BNP before every session",
     "D. Echocardiographic EF confirmation weekly"],
  a:"B", section:"Phase II" },

// ══════════════════════════════════════════════════════════════════
// SECTION 4: PHASE III & IV (Q101-125)
// ══════════════════════════════════════════════════════════════════
{ q:"101. Phase III cardiac rehabilitation is characterized by:",
  o:["A. Continuous ECG monitoring like Phase II",
     "B. Transition toward independent exercise with periodic (not continuous) monitoring",
     "C. Exclusively home-based exercise with no supervision",
     "D. Restriction to 10 minutes of exercise per session"],
  a:"B", section:"Phase III/IV" },

{ q:"102. The AHA secondary prevention weekly aerobic exercise target achieved by the end of Phase III is:",
  o:["A. 60-90 min/week","B. 100-120 min/week","C. 150-300 min/week","D. 400-500 min/week"],
  a:"C", section:"Phase III/IV" },

{ q:"103. The intensity progression target at Phase III completion is approximately:",
  o:["A. 40-50% HRR","B. 50-60% HRR","C. 70-85% HRR","D. 90-100% HRR"],
  a:"C", section:"Phase III/IV" },

{ q:"104. During Phase III, resistance training should progress to approximately:",
  o:["A. 10-20% of 1RM for maintenance only",
     "B. 3 sets × 8-12 reps at up to 60-70% of 1RM",
     "C. 1 set × 5 reps at maximum load",
     "D. No resistance training — aerobic only in Phase III"],
  a:"B", section:"Phase III/IV" },

{ q:"105. Step count target at Phase III completion is approximately:",
  o:["A. 2,000-3,000 steps/day","B. 5,000-6,000 steps/day","C. 8,000-10,000 steps/day","D. 15,000-20,000 steps/day"],
  a:"C", section:"Phase III/IV" },

{ q:"106. Phase IV cardiac rehabilitation is best described as:",
  o:["A. Inpatient intensive rehabilitation after cardiac arrest",
     "B. Lifelong independent community-based exercise and lifestyle maintenance",
     "C. 36 additional supervised sessions beyond Phase II",
     "D. Hospital-based monitored exercise only"],
  a:"B", section:"Phase III/IV" },

{ q:"107. According to AHA/ACC guidelines, the Phase IV aerobic exercise target is at minimum:",
  o:["A. 60 min/week light activity","B. 150 min/week moderate intensity","C. 300 min/week vigorous intensity","D. 500 min/week moderate activity"],
  a:"B", section:"Phase III/IV" },

{ q:"108. During Phase IV, resistance training should be performed:",
  o:["A. Daily without rest days","B. Once per week only","C. 2 days/week covering major muscle groups with progressive overload","D. Only if supervised by a physical therapist"],
  a:"C", section:"Phase III/IV" },

{ q:"109. Flexibility and balance exercises in Phase IV are particularly important for which population?",
  o:["A. Post-CABG patients under 40 years","B. Young athletes returning to sport","C. Elderly patients for fall prevention","D. Patients with HOCM"],
  a:"C", section:"Phase III/IV" },

{ q:"110. Phase IV monitoring of cardiovascular risk factors should include:",
  o:["A. No follow-up needed — patient is independent",
     "B. Annual review with cardiologist or primary care; repeat ETT if indicated; lab monitoring",
     "C. Monthly echocardiography",
     "D. Weekly Holter monitoring indefinitely"],
  a:"B", section:"Phase III/IV" },

{ q:"111. Group-based Phase III sessions are beneficial because they:",
  o:["A. Reduce the need for any medical supervision permanently",
     "B. Foster peer support, reduce isolation, and improve long-term adherence",
     "C. Allow patients to exercise without any monitoring",
     "D. Replace the need for Phase II entirely"],
  a:"B", section:"Phase III/IV" },

{ q:"112. The step count target at the entry of Phase III (coming from Phase II) is:",
  o:["A. 1,000-2,000 steps/day","B. 5,000-7,000 steps/day","C. 10,000-12,000 steps/day","D. 15,000 steps/day minimum"],
  a:"B", section:"Phase III/IV" },

{ q:"113. Which technology is encouraged in Phase IV to improve adherence and self-monitoring?",
  o:["A. Bedside echocardiography","B. Wearable devices (HR monitors, pedometers, smartphone apps)","C. Continuous Holter monitoring","D. Implanted hemodynamic sensors only"],
  a:"B", section:"Phase III/IV" },

{ q:"114. The Borg RPE target during Phase IV exercise should be approximately:",
  o:["A. 6-8 (extremely light)","B. 9-11 (very light)","C. 12-15 (moderate to somewhat hard)","D. 17-19 (very hard)"],
  a:"C", section:"Phase III/IV" },

{ q:"115. Vigorous intensity aerobic exercise in Phase IV (AHA secondary prevention) requires a minimum of how many minutes per week?",
  o:["A. 30 min/week","B. 75-150 min/week","C. 250 min/week","D. 400 min/week"],
  a:"B", section:"Phase III/IV" },

// ══════════════════════════════════════════════════════════════════
// SECTION 5: SPECIAL POPULATIONS (Q116-145)
// ══════════════════════════════════════════════════════════════════
{ q:"116. In HFrEF patients entering cardiac rehabilitation, the preferred exercise mode is:",
  o:["A. High-impact jumping exercises","B. Isometric heavy resistance training","C. Stationary cycling (constant preload/afterload)","D. Running on treadmill at high incline"],
  a:"C", section:"Special Populations" },

{ q:"117. Before starting CR exercise in HFrEF, the patient must be:",
  o:["A. Off all diuretics for 48 hours",
     "B. Euvolemic and stable for ≥4 weeks on optimized GDMT",
     "C. Admitted to hospital for supervised initiation",
     "D. Free of any symptoms at maximal exercise"],
  a:"B", section:"Special Populations" },

{ q:"118. A HFrEF patient gains 2 kg overnight before a Phase II session. The correct response is:",
  o:["A. Continue the session as planned",
     "B. Hold exercise and notify the physician — possible decompensation",
     "C. Reduce session intensity by 50% and continue",
     "D. Add diuretics and proceed with the session"],
  a:"B", section:"Special Populations" },

{ q:"119. In HFrEF, the starting exercise intensity for Phase II should be:",
  o:["A. 70-80% HRR from the first session",
     "B. Very low — 40-50% HRR; 2-3 METs; RPE 10-12",
     "C. 60-70% HRR from Week 1",
     "D. HIIT from the first session"],
  a:"B", section:"Special Populations" },

{ q:"120. GDMT in HFrEF for cardiac rehabilitation eligibility stands for:",
  o:["A. General Disease Management Therapy",
     "B. Guideline-Directed Medical Therapy (beta-blocker, ACE-I/ARB/ARNi, MRA)",
     "C. Graded Dynamic Movement Training",
     "D. Goal-Directed Monitoring Technique"],
  a:"B", section:"Special Populations" },

{ q:"121. In older adults, CR participation reduces mortality by what percentage compared to non-participants (Braunwald's Heart Disease)?",
  o:["A. 5-10%","B. 12-15%","C. 21-34%","D. 40-50%"],
  a:"C", section:"Special Populations" },

{ q:"122. Only what percentage of Medicare-eligible patients actually participate in CR?",
  o:["A. ~50%","B. ~30%","C. ~25%","D. ~12%"],
  a:"D", section:"Special Populations" },

{ q:"123. For post-CABG patients, upper extremity resistance training is restricted for how long to allow sternal healing?",
  o:["A. 2 weeks","B. 3-4 weeks","C. 6-8 weeks","D. 12 weeks minimum"],
  a:"C", section:"Special Populations" },

{ q:"124. Post-CABG sternal precautions include:",
  o:["A. No walking at all for 6 weeks",
     "B. No pushing/pulling >5-10 lbs and no reaching behind the back",
     "C. No lower extremity exercise for 4 weeks",
     "D. No nutritional modification for 8 weeks"],
  a:"B", section:"Special Populations" },

{ q:"125. A major barrier to older adult CR participation is:",
  o:["A. Excessive energy levels in elderly",
     "B. Logistical barriers including lack of referral, transportation, and socioeconomic factors",
     "C. Contraindication in all patients over 75",
     "D. Phase II not approved for elderly by Medicare"],
  a:"B", section:"Special Populations" },

{ q:"126. Women are identified as a group with suboptimal CR participation because:",
  o:["A. CR is contraindicated for women due to hormonal interactions",
     "B. Women are significantly under-referred despite equal clinical benefits",
     "C. Women have higher side-effect rates from exercise",
     "D. Female-specific CR programs do not exist"],
  a:"B", section:"Special Populations" },

{ q:"127. For post-valve surgery patients on anticoagulation, the most important pre-exercise consideration is:",
  o:["A. Ensuring resting HR <60 bpm",
     "B. INR must be therapeutic before initiating vigorous exercise (mechanical valves)",
     "C. EF must be >55% before starting",
     "D. No modifications needed — proceed as standard CR"],
  a:"B", section:"Special Populations" },

{ q:"128. Which exercise is specifically cautioned in post-valve surgery patients to avoid?",
  o:["A. Walking","B. Cycling","C. Valsalva maneuver during resistance training","D. Stretching"],
  a:"C", section:"Special Populations" },

{ q:"129. Geriatric CR should include which additional component beyond standard aerobic and resistance training?",
  o:["A. High-impact plyometrics","B. Sprint interval training","C. Balance and fall-prevention training","D. Competitive sport preparation"],
  a:"C", section:"Special Populations" },

{ q:"130. In a post-cardiac transplant patient in Phase II, what is a key physiologic difference in exercise response?",
  o:["A. Normal sinus node control of HR",
     "B. Denervated heart — chronotropic response to exercise is delayed and blunted",
     "C. Hypertensive response to any exertion",
     "D. Resting HR always <60 bpm"],
  a:"B", section:"Special Populations" },

// ══════════════════════════════════════════════════════════════════
// SECTION 6: NON-EXERCISE COMPONENTS (Q131-155)
// ══════════════════════════════════════════════════════════════════
{ q:"131. What percentage of post-MI patients experience depression or anxiety?",
  o:["A. 2-5%","B. 5-10%","C. 20-40%","D. 50-60%"],
  a:"C", section:"Non-Exercise Components" },

{ q:"132. Which dietary fat should be ELIMINATED entirely from the cardiac rehabilitation diet?",
  o:["A. Monounsaturated fats (olive oil)","B. Omega-3 polyunsaturated fats","C. Trans fats (partially hydrogenated oils)","D. Short-chain saturated fats"],
  a:"C", section:"Non-Exercise Components" },

{ q:"133. The recommended sodium restriction for most cardiac patients in CR is:",
  o:["A. <5,000 mg/day","B. <3,500 mg/day","C. <2,300 mg/day","D. <500 mg/day"],
  a:"C", section:"Non-Exercise Components" },

{ q:"134. The sodium restriction for HFrEF patients is more stringent at:",
  o:["A. <3,000 mg/day","B. <1,500-2,000 mg/day","C. <1,000 mg/day","D. <500 mg/day"],
  a:"B", section:"Non-Exercise Components" },

{ q:"135. In CR nutritional counseling, the target BMI range for cardiovascular health is:",
  o:["A. 18-22 kg/m²","B. 20-25 kg/m²","C. 25-30 kg/m²","D. 28-32 kg/m²"],
  a:"B", section:"Non-Exercise Components" },

{ q:"136. Which medication class provides cardiorenal protection in diabetes patients in CR risk factor management?",
  o:["A. Sulfonylureas","B. DPP-4 inhibitors","C. SGLT2 inhibitors","D. Meglitinides"],
  a:"C", section:"Non-Exercise Components" },

{ q:"137. The HbA1c target for diabetic CR patients is generally:",
  o:["A. <10%","B. <8.5%","C. <7.0%","D. <5.5%"],
  a:"C", section:"Non-Exercise Components" },

{ q:"138. First-line pharmacological smoking cessation for CR patients includes:",
  o:["A. Hydrocodone","B. Benzodiazepines","C. Varenicline (Champix/Chantix) and NRT","D. Metformin"],
  a:"C", section:"Non-Exercise Components" },

{ q:"139. The LDL target for very high-risk CVD patients with recurrent events is:",
  o:["A. <100 mg/dL","B. <70 mg/dL","C. <55 mg/dL","D. <40 mg/dL"],
  a:"C", section:"Non-Exercise Components" },

{ q:"140. Which drug class is recommended if statin alone does not achieve LDL target in CR patients?",
  o:["A. Fibrates as first add-on","B. Bile acid sequestrants as first add-on","C. Ezetimibe, then PCSK9 inhibitors if still not at target","D. Niacin as first add-on"],
  a:"C", section:"Non-Exercise Components" },

{ q:"141. Cognitive behavioral therapy (CBT) in Phase II CR primarily addresses:",
  o:["A. Myocardial contractility","B. Depression, anxiety, and maladaptive health behaviors","C. Lipid management","D. Surgical wound healing"],
  a:"B", section:"Non-Exercise Components" },

{ q:"142. The waist circumference target in CR for cardiovascular health (men) is:",
  o:["A. <80 cm","B. <88 cm","C. <102 cm","D. <120 cm"],
  a:"C", section:"Non-Exercise Components" },

{ q:"143. Saturated fat intake should be limited to what percentage of total daily calories in CR?",
  o:["A. <15%","B. <10%","C. <7%","D. <3%"],
  a:"C", section:"Non-Exercise Components" },

{ q:"144. Progressive muscle relaxation and guided imagery in CR primarily reduce:",
  o:["A. LDL levels","B. Cortisol levels and sympathetic tone","C. Exercise capacity","D. Medication adherence"],
  a:"B", section:"Non-Exercise Components" },

{ q:"145. Alcohol intake recommendation in CR is to limit to a maximum of how many drinks per day for men?",
  o:["A. 1 drink/day","B. 2 drinks/day","C. 3 drinks/day","D. 4 drinks/day"],
  a:"B", section:"Non-Exercise Components" },

// ══════════════════════════════════════════════════════════════════
// SECTION 7: EXERCISE PHYSIOLOGY & PARAMETERS (Q146-170)
// ══════════════════════════════════════════════════════════════════
{ q:"146. VO2 peak (peak oxygen consumption) is the gold standard measure of:",
  o:["A. Myocardial perfusion","B. Cardiorespiratory fitness","C. Skeletal muscle strength","D. Pulmonary compliance"],
  a:"B", section:"Exercise Physiology" },

{ q:"147. The Borg RPE scale ranges from:",
  o:["A. 1-10","B. 0-20","C. 6-20","D. 1-100"],
  a:"C", section:"Exercise Physiology" },

{ q:"148. Slow walking at 1.5 mph corresponds to approximately:",
  o:["A. 1.0 MET","B. 2.0 METs","C. 4.0 METs","D. 6.0 METs"],
  a:"B", section:"Exercise Physiology" },

{ q:"149. Brisk walking at 3.5 mph corresponds to approximately:",
  o:["A. 2.0 METs","B. 3.0 METs","C. 4.0-5.0 METs","D. 7.0-8.0 METs"],
  a:"C", section:"Exercise Physiology" },

{ q:"150. Jogging at 5 mph corresponds to approximately:",
  o:["A. 4.0 METs","B. 6.0 METs","C. 8.0 METs","D. 12.0 METs"],
  a:"C", section:"Exercise Physiology" },

{ q:"151. Sexual activity at moderate effort is equivalent to approximately:",
  o:["A. 1-2 METs","B. 3-5 METs","C. 7-8 METs","D. 10-12 METs"],
  a:"B", section:"Exercise Physiology" },

{ q:"152. The 1-MET standard is defined as:",
  o:["A. Walking 1 mile in 15 minutes",
     "B. Oxygen consumption at rest (~3.5 mL O2/kg/min)",
     "C. Maximum oxygen consumption during sprint exercise",
     "D. The heart rate response to 1 minute of moderate exercise"],
  a:"B", section:"Exercise Physiology" },

{ q:"153. Heart rate reserve (HRR) is calculated as:",
  o:["A. HRmax - HR at peak exercise",
     "B. HRmax - HRrest",
     "C. HRrest / HRmax × 100",
     "D. HRmax + HRrest"],
  a:"B", section:"Exercise Physiology" },

{ q:"154. A patient has HRmax 160 bpm and resting HR 70 bpm. Their HRR is:",
  o:["A. 70 bpm","B. 90 bpm","C. 115 bpm","D. 230 bpm"],
  a:"B", section:"Exercise Physiology" },

{ q:"155. Using 60% HRR from Q154 (HRmax 160, HRrest 70), the training HR by Karvonen is:",
  o:["A. 96 bpm","B. 104 bpm","C. 124 bpm","D. 138 bpm"],
  a:"C", section:"Exercise Physiology" },

{ q:"156. A patient on a beta-blocker has an apparent HRmax of only 120 bpm on ETT. The exercise HR prescription should be:",
  o:["A. Still based on 220-age formula",
     "B. Based on the measured peak HR from ETT — not the age-predicted formula",
     "C. Simply resting HR + 10 bpm",
     "D. Not prescribed — beta-blockers contraindicate HR-based prescription"],
  a:"B", section:"Exercise Physiology" },

{ q:"157. HIIT (High-Intensity Interval Training) has been shown to be more effective than moderate continuous training primarily for improving:",
  o:["A. Serum HDL only","B. LV wall thickness only","C. VO2 max and cardiorespiratory fitness","D. Resting HR only"],
  a:"C", section:"Exercise Physiology" },

{ q:"158. The recommended recovery interval intensity in a 4×4 HIIT protocol is approximately:",
  o:["A. 20-30% HRmax","B. 50-70% HRmax","C. 80% HRmax","D. Complete rest (0% HRmax)"],
  a:"B", section:"Exercise Physiology" },

{ q:"159. Low cardiorespiratory fitness is associated with:",
  o:["A. Lower all-cause mortality","B. Decreased coronary calcium score","C. Higher all-cause mortality risk","D. Improved diastolic function"],
  a:"C", section:"Exercise Physiology" },

{ q:"160. Which field test is most commonly used to assess exercise capacity in cardiac rehabilitation?",
  o:["A. Incremental shuttle run test","B. 6-minute walk test (6MWT)","C. Cooper 12-minute run","D. Harvard Step Test"],
  a:"B", section:"Exercise Physiology" },

{ q:"161. Isometric exercises (e.g., sustained gripping or wall-sit) in CR are generally AVOIDED because they:",
  o:["A. Reduce muscle strength",
     "B. Cause a marked pressor response (BP spike) with minimal cardiac output increase",
     "C. Are ineffective for muscle conditioning",
     "D. Cause hypotension in cardiac patients"],
  a:"B", section:"Exercise Physiology" },

{ q:"162. The Valsalva maneuver is dangerous during resistance training in CR because it:",
  o:["A. Causes hypoglycemia",
     "B. Dramatically increases intrathoracic pressure, reducing venous return and causing BP spike followed by hypotension",
     "C. Triggers bronchospasm",
     "D. Lowers LDL acutely"],
  a:"B", section:"Exercise Physiology" },

{ q:"163. Which of the following is the best indicator that aerobic intensity is appropriate in a Phase II session?",
  o:["A. Patient is completely breathless and cannot speak",
     "B. Patient can speak in short sentences (talk test positive)",
     "C. Patient HR exceeds 85% HRmax",
     "D. Patient's SpO2 drops to 91%"],
  a:"B", section:"Exercise Physiology" },

{ q:"164. The primary cardiovascular adaptation to regular aerobic training in CR includes:",
  o:["A. Increased LV wall thickness (concentric hypertrophy only)",
     "B. Increased stroke volume, reduced resting HR, improved peripheral O2 utilization",
     "C. Decreased cardiac output at rest",
     "D. Increased LDL receptor expression"],
  a:"B", section:"Exercise Physiology" },

{ q:"165. Aquatic (water-based) exercise in CR is beneficial primarily because:",
  o:["A. It eliminates the need for ECG monitoring",
     "B. Buoyancy reduces joint load; water resistance provides gentle cardiovascular training",
     "C. Water prevents any arrhythmia",
     "D. It is the only mode safe for post-valve patients"],
  a:"B", section:"Exercise Physiology" },

// ══════════════════════════════════════════════════════════════════
// SECTION 8: HOME-BASED & DIGITAL CR + SAFETY (Q166-185)
// ══════════════════════════════════════════════════════════════════
{ q:"166. Home-based CR is considered appropriate for which risk category?",
  o:["A. High-risk patients only","B. Low to moderate risk patients","C. All risk categories equally","D. Only patients with HFpEF"],
  a:"B", section:"Home-Based & Safety" },

{ q:"167. The AHA cardiac arrest rate during supervised CR exercise is approximately:",
  o:["A. 1 per 10,000 patient-hours","B. 1 per 50,000 patient-hours","C. 1 per 116,906 patient-hours","D. 1 per 1,000,000 patient-hours"],
  a:"C", section:"Home-Based & Safety" },

{ q:"168. What device can be used for ECG monitoring in home-based CR?",
  o:["A. A standard hospital bedside monitor","B. Wearable ECG devices (e.g., Kardia, mobile Holter)","C. In-office 12-lead ECG only","D. Implanted pacemaker data only"],
  a:"B", section:"Home-Based & Safety" },

{ q:"169. Compared to center-based CR, home-based CR programs show:",
  o:["A. Significantly worse clinical outcomes in all studies",
     "B. Equivalent benefits in low-risk patients with growing evidence",
     "C. No evidence of cardiovascular benefit",
     "D. Superior outcomes in high-risk patients"],
  a:"B", section:"Home-Based & Safety" },

{ q:"170. Hybrid CR programs combine:",
  o:["A. Phase I and Phase IV only","B. Center-based supervised sessions with home-based exercise","C. Pharmacological and surgical interventions only","D. Inpatient and ICU rehabilitation"],
  a:"B", section:"Home-Based & Safety" },

{ q:"171. A CR patient reports onset of angina at RPE 13 during a Phase II session. The appropriate action is:",
  o:["A. Continue the session — angina at this RPE is expected",
     "B. Stop exercise, have patient sit/rest, administer sublingual nitrate, call physician",
     "C. Reduce to RPE 12 and continue",
     "D. Start HIIT to push through the angina threshold"],
  a:"B", section:"Home-Based & Safety" },

{ q:"172. The French multicenter study reported a cardiac arrest rate during CR exercise of approximately:",
  o:["A. 10 per million patient-hours",
     "B. 1.3 per million patient-hours",
     "C. 1.3 per thousand patient-hours",
     "D. 5 per hundred thousand patient-hours"],
  a:"B", section:"Home-Based & Safety" },

{ q:"173. Contraindications to thermal modalities (heat packs) in CR patients include:",
  o:["A. Mild stable angina","B. Well-healed surgical scars","C. Areas with impaired sensation or active malignancy","D. Post-CABG patients after 8 weeks"],
  a:"C", section:"Home-Based & Safety" },

{ q:"174. In a CR session, a patient suddenly develops dizziness and lightheadedness on the treadmill. You should:",
  o:["A. Increase treadmill speed to overcome dizziness",
     "B. Stop the treadmill immediately, help patient sit safely, check BP and HR",
     "C. Tell the patient to hold the handrails and continue",
     "D. Administer IV fluids immediately"],
  a:"B", section:"Home-Based & Safety" },

{ q:"175. Which of the following is TRUE about the safety profile of supervised cardiac rehabilitation?",
  o:["A. CR has a high rate of adverse events and is considered risky",
     "B. CR is demonstrably safe with very low rates of adverse events due to screening and monitoring",
     "C. CR should only be offered in ICU settings due to safety concerns",
     "D. CR safety data are insufficient to draw conclusions"],
  a:"B", section:"Home-Based & Safety" },

// ══════════════════════════════════════════════════════════════════
// SECTION 9: EVIDENCE & OUTCOMES (Q176-200)
// ══════════════════════════════════════════════════════════════════
{ q:"176. Meta-analyses show that CR is associated with approximately what relative risk reduction in cardiovascular mortality?",
  o:["A. 5-10%","B. 15-20%","C. 26-31%","D. 50-60%"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"177. CR is associated with what reduction in all-cause mortality in RCT meta-analyses?",
  o:["A. 5%","B. 10-15%","C. 20-26%","D. 40-50%"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"178. Systematic reviews show CR reduces re-hospitalization rates by approximately:",
  o:["A. 5%","B. 18-25%","C. 40-50%","D. 60-70%"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"179. Following CR, the typical improvement in VO2 peak is approximately:",
  o:["A. 1-3%","B. 5-8%","C. 11-16%","D. 30-40%"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"180. In low-fitness patients at baseline, each 1-MET improvement in fitness with CR reduces mortality by:",
  o:["A. 5%","B. 13%","C. 20%","D. 30%"],
  a:"D", section:"Evidence & Outcomes" },

{ q:"181. The HF-ACTION trial was a landmark RCT demonstrating CR benefits in which population?",
  o:["A. Post-CABG patients","B. Heart failure with reduced ejection fraction (HFrEF)","C. Stable angina only","D. Post-valve replacement patients"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"182. CR reduces recurrent MI by approximately:",
  o:["A. 5%","B. 10%","C. 17-21%","D. 40%"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"183. What is the primary economic benefit of CR demonstrated in studies?",
  o:["A. CR increases total healthcare costs significantly",
     "B. CR reduces hospitalizations and emergency visits, resulting in lower overall medical costs",
     "C. CR has no measurable impact on healthcare costs",
     "D. CR saves money only in patients over 75"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"184. Low responders to CR exercise training had what increase in mortality compared to high responders (De Schutter et al.)?",
  o:["A. Equal mortality","B. 1.5x higher mortality","C. 2x higher mortality","D. 3x higher mortality"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"185. Which validated questionnaire measures health-related quality of life in cardiac patients and is used as a CR outcome measure?",
  o:["A. PHQ-9","B. GAD-7","C. MacNew Heart Disease Quality of Life questionnaire and SF-36","D. AUDIT-C"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"186. What is the approximate mean follow-up period in the De Schutter et al. study showing mortality differences between responders and non-responders?",
  o:["A. 1 year","B. 3 years","C. 6.4 years","D. 10 years"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"187. The SMARTEX-HF trial specifically evaluated which CR intervention in heart failure?",
  o:["A. Dietary counseling only","B. HIIT vs. moderate continuous training in HFrEF","C. Psychological therapy vs. exercise","D. Home-based vs. center-based for post-STEMI"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"188. Studies on CR and psychosocial outcomes show significant reduction in scores on which instruments?",
  o:["A. MMSE and MoCA (cognitive scales)",
     "B. PHQ-9 (depression) and GAD-7 (anxiety) scores",
     "C. NYHA functional class alone",
     "D. 6-minute walk test distance"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"189. CR improves patient outcomes beyond exercise alone primarily because:",
  o:["A. It provides only supervised exercise without education",
     "B. Its multidisciplinary approach addresses exercise, diet, psychosocial health, and all modifiable risk factors simultaneously",
     "C. It primarily reduces LDL through statin intensification",
     "D. It eliminates the need for any cardiac medications"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"190. The primary reason Phase I formal programs have declined in the United States is:",
  o:["A. Lack of evidence for Phase I effectiveness",
     "B. Shortened hospital stays after MI and revascularization",
     "C. Increasing patient preference for home-based programs",
     "D. Withdrawal of Medicare coverage for Phase I"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"191. Which of the following represents the CORRECT sequence of cardiac rehabilitation phases?",
  o:["A. Outpatient → Inpatient → Home maintenance → Community",
     "B. Inpatient (Phase I) → Supervised Outpatient (Phase II) → Extended Outpatient (Phase III) → Lifelong Maintenance (Phase IV)",
     "C. Home-based → Supervised → Inpatient → Lifelong",
     "D. Phase II always precedes Phase I in modern protocols"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"192. A CR patient improves their treadmill capacity from 5 METs to 6 METs after Phase II. Their approximate mortality reduction is:",
  o:["A. 5%","B. 10%","C. 13% (each 1-MET increase)","D. 30% (only in low-fitness baseline)"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"193. CR outcomes are BEST measured using which combination?",
  o:["A. Body weight and step count only",
     "B. VO2 peak, QoL questionnaires, risk factor targets, psychosocial screening, and hospitalization rates",
     "C. Resting ECG and resting BP alone",
     "D. LDL level at 6 months only"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"194. Which of the following is a true statement about gender disparity in CR?",
  o:["A. Women enroll at higher rates than men",
     "B. CR benefits are greater in women than in men",
     "C. Women are under-referred and under-enrolled despite equal benefits",
     "D. CR is contraindicated in post-menopausal women"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"195. The CROS study evaluated which specific aspect of CR delivery?",
  o:["A. HIIT vs. moderate intensity in STEMI patients",
     "B. Equivalence of home-based vs. centre-based CR outcomes in low-risk patients",
     "C. Nutritional counseling alone vs. exercise in HFrEF",
     "D. Phase I duration in post-CABG patients"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"196. In a patient with resting SpO2 of 91% on room air before a Phase II session, the correct action is:",
  o:["A. Begin the session at reduced intensity",
     "B. Defer exercise; assess clinical cause of hypoxemia and notify physician",
     "C. Provide 2L nasal cannula O2 and proceed with the session",
     "D. Proceed if the patient feels well"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"197. Which of the following is an example of the 'compensatory' approach in CR (vs. restorative)?",
  o:["A. Strengthening exercises to restore pre-morbid muscle function",
     "B. Teaching one-handed dressing techniques when full upper limb function cannot be restored",
     "C. Walking training to improve cardiovascular fitness",
     "D. Dietary counseling to reduce LDL"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"198. An interprofessional CR team typically does NOT include:",
  o:["A. Cardiologist / physician","B. Physical therapist","C. Orthopedic surgeon","D. Dietitian and psychologist"],
  a:"C", section:"Evidence & Outcomes" },

{ q:"199. A patient with pulmonary embolism (PE) diagnosed 2 weeks ago wishes to start Phase II CR. The correct approach is:",
  o:["A. Start immediately with low-intensity exercise",
     "B. Defer enrollment — recent PE is a contraindication to CR exercise",
     "C. Enroll but restrict to only 5 minutes per session",
     "D. Enroll only if INR >3.0"],
  a:"B", section:"Evidence & Outcomes" },

{ q:"200. The overarching goal of all phases of cardiac rehabilitation is:",
  o:["A. Achieving maximal VO2 peak comparable to healthy individuals",
     "B. Reducing the need for all cardiac medications",
     "C. Maximizing functional capacity, reducing cardiovascular risk, and improving quality of life through lifelong healthy behaviors",
     "D. Ensuring all patients return to competitive athletic performance"],
  a:"C", section:"Evidence & Outcomes" },

];

// ─── Build answer key array ───────────────────────────────────────────────────
const answerKey = mcqs.map((m, i) => ({ num: i+1, ans: m.a, section: m.section }));

// ─── Helpers ─────────────────────────────────────────────────────────────────
function spacer() {
  return new Paragraph({ spacing: { before: 60, after: 60 }, children: [new TextRun("")] });
}
function pageBreak() {
  return new Paragraph({ children: [new PageBreak()] });
}
function sectionHeader(text, color) {
  return new Paragraph({
    spacing: { before: 300, after: 120 },
    shading: { type: ShadingType.SOLID, color: color },
    indent: { left: 180, right: 180 },
    children: [new TextRun({ text, bold: true, size: 24, color: WHITE, font: "Calibri" })],
  });
}

// ─── Build MCQ paragraphs ─────────────────────────────────────────────────────
function buildQuestion(m, index) {
  const paras = [];
  // Question text
  paras.push(new Paragraph({
    spacing: { before: 120, after: 40 },
    children: [
      new TextRun({ text: m.q, bold: true, size: 19, color: DARK_BLUE, font: "Calibri" }),
    ],
  }));
  // Options
  m.o.forEach(opt => {
    const isCorrect = opt.startsWith(m.a + ".");
    paras.push(new Paragraph({
      spacing: { before: 20, after: 20 },
      indent: { left: 280 },
      children: [
        new TextRun({ text: opt, size: 18, color: DARK_TEXT, font: "Calibri" }),
      ],
    }));
  });
  paras.push(spacer());
  return paras;
}

// ─── Group questions by section ──────────────────────────────────────────────
const sections = [
  { name: "SECTION 1: OVERVIEW OF CARDIAC REHABILITATION (Q1-25)", color: DARK_BLUE, range: [0,25] },
  { name: "SECTION 2: PHASE I — INPATIENT REHABILITATION (Q26-55)", color: "1A5276", range: [25,55] },
  { name: "SECTION 3: PHASE II — SUPERVISED OUTPATIENT (Q56-100)", color: "1F618D", range: [55,100] },
  { name: "SECTION 4: PHASE III & IV — MAINTENANCE (Q101-115)", color: "2874A6", range: [100,115] },
  { name: "SECTION 5: SPECIAL POPULATIONS (Q116-130)", color: "2980B9", range: [115,130] },
  { name: "SECTION 6: NON-EXERCISE COMPONENTS (Q131-145)", color: "1A5276", range: [130,145] },
  { name: "SECTION 7: EXERCISE PHYSIOLOGY & PARAMETERS (Q146-165)", color: "154360", range: [145,165] },
  { name: "SECTION 8: HOME-BASED CR & SAFETY (Q166-175)", color: "1B2631", range: [165,175] },
  { name: "SECTION 9: EVIDENCE & OUTCOMES (Q176-200)", color: "145A32", range: [175,200] },
];

// ─── Answer Key Table ─────────────────────────────────────────────────────────
function buildAnswerTable() {
  const cols = 5; // 5 columns: Q# | Ans | Q# | Ans | Q# | Ans ...
  const rows = [];
  // Header row
  const headerCells = [];
  for (let c = 0; c < cols; c++) {
    headerCells.push(new TableCell({
      shading: { type: ShadingType.SOLID, color: DARK_BLUE },
      width: { size: 20, type: WidthType.PERCENTAGE },
      children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: c % 2 === 0 ? "Q#" : "Answer", bold: true, size: 18, color: WHITE, font: "Calibri" })] })],
    }));
  }
  // Build pairs: Q + Answer
  const pairs = answerKey.map(k => [`Q${k.num}`, `${k.ans}`]);
  // Arrange in 5-column layout: [Q, A, Q, A, Q, A, Q, A, Q, A] per row (5 Q-A pairs per row with 2 cols each = 10 columns)
  // Actually: 4 pairs per row (Q Ans Q Ans Q Ans Q Ans) = 8 columns, or use Q + Ans in alternating cells
  // We'll do 4 Q-A pairs per row = 8 cells per row
  const pairsPerRow = 5;
  const headers2 = [];
  for (let c = 0; c < pairsPerRow; c++) {
    headers2.push(
      new TableCell({ shading: { type: ShadingType.SOLID, color: DARK_BLUE }, width: { size: 10, type: WidthType.PERCENTAGE }, children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "Q#", bold: true, size: 17, color: WHITE, font: "Calibri" })] })] }),
      new TableCell({ shading: { type: ShadingType.SOLID, color: MID_BLUE }, width: { size: 10, type: WidthType.PERCENTAGE }, children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "Ans", bold: true, size: 17, color: WHITE, font: "Calibri" })] })] }),
    );
  }
  const tableRows = [new TableRow({ tableHeader: true, children: headers2 })];
  for (let i = 0; i < pairs.length; i += pairsPerRow) {
    const cells = [];
    for (let c = 0; c < pairsPerRow; c++) {
      const pair = pairs[i + c];
      const ri = Math.floor(i / pairsPerRow);
      const bg = ri % 2 === 0 ? WHITE : GRAY_BG;
      if (pair) {
        cells.push(
          new TableCell({ shading: { type: ShadingType.SOLID, color: bg }, width: { size: 10, type: WidthType.PERCENTAGE }, children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: pair[0], size: 17, color: DARK_TEXT, font: "Calibri", bold: true })] })] }),
          new TableCell({ shading: { type: ShadingType.SOLID, color: pair[1] === "A" ? "D5F5E3" : pair[1] === "B" ? "D6EAF8" : pair[1] === "C" ? "FEF9E7" : "FDEDEC" }, width: { size: 10, type: WidthType.PERCENTAGE }, children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: pair[1], size: 17, color: DARK_TEXT, bold: true, font: "Calibri" })] })] }),
        );
      } else {
        cells.push(
          new TableCell({ width: { size: 10, type: WidthType.PERCENTAGE }, children: [new Paragraph({ children: [new TextRun("")]  })] }),
          new TableCell({ width: { size: 10, type: WidthType.PERCENTAGE }, children: [new Paragraph({ children: [new TextRun("")]  })] }),
        );
      }
    }
    tableRows.push(new TableRow({ children: cells }));
  }
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: tableRows,
    borders: {
      top: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      bottom: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      left: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      right: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      insideH: { style: BorderStyle.SINGLE, size: 2, color: "BDC3C7" },
      insideV: { style: BorderStyle.SINGLE, size: 2, color: "BDC3C7" },
    },
  });
}

// ─── Build full document children ────────────────────────────────────────────
const children = [];

// Title
children.push(
  new Paragraph({
    spacing: { before: 400, after: 0 },
    alignment: AlignmentType.CENTER,
    shading: { type: ShadingType.SOLID, color: DARK_BLUE },
    children: [
      new TextRun({ text: "CARDIAC REHABILITATION", bold: true, size: 52, color: WHITE, font: "Calibri", break: 1 }),
      new TextRun({ text: "Phases & Exercise Progression", bold: true, size: 36, color: "A9CCE3", font: "Calibri", break: 1 }),
    ],
  }),
  new Paragraph({
    spacing: { before: 0, after: 0 },
    alignment: AlignmentType.CENTER,
    shading: { type: ShadingType.SOLID, color: MID_BLUE },
    children: [
      new TextRun({ text: "200 Multiple Choice Questions  |  Comprehensive Examination", bold: true, size: 24, color: WHITE, font: "Calibri", break: 1 }),
      new TextRun({ text: "Based on Fuster & Hurst's The Heart (15th Ed.)  •  Braunwald's Heart Disease  •  AHA/ACC Guidelines  •  StatPearls", size: 16, color: "D6EAF8", font: "Calibri", break: 1 }),
    ],
  }),
  spacer(),
  new Paragraph({
    alignment: AlignmentType.CENTER,
    spacing: { before: 60, after: 80 },
    children: [
      new TextRun({ text: "Instructions: ", bold: true, size: 20, color: DARK_BLUE, font: "Calibri" }),
      new TextRun({ text: "Select ONE best answer for each question. Answer key is provided at the end of the document.", size: 20, color: DARK_TEXT, font: "Calibri" }),
    ],
  }),
  new Paragraph({
    alignment: AlignmentType.CENTER,
    spacing: { before: 0, after: 120 },
    children: [
      new TextRun({ text: "Total Questions: 200  |  Recommended Time: 3 hours  |  Passing Score: 70% (140/200)", size: 19, color: MID_BLUE, font: "Calibri", italics: true }),
    ],
  }),
);

// Distribution table
children.push(
  new Paragraph({ spacing: { before: 60, after: 60 }, children: [new TextRun({ text: "Question Distribution by Section:", bold: true, size: 20, color: DARK_BLUE, font: "Calibri" })] }),
  new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [
      new TableRow({ tableHeader: true, children: [
        new TableCell({ shading: { type: ShadingType.SOLID, color: DARK_BLUE }, children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "Section", bold: true, size: 18, color: WHITE, font: "Calibri" })] })] }),
        new TableCell({ shading: { type: ShadingType.SOLID, color: DARK_BLUE }, children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "Topic", bold: true, size: 18, color: WHITE, font: "Calibri" })] })] }),
        new TableCell({ shading: { type: ShadingType.SOLID, color: DARK_BLUE }, children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "Questions", bold: true, size: 18, color: WHITE, font: "Calibri" })] })] }),
      ]}),
      ...[ ["Section 1","Overview of Cardiac Rehabilitation","Q1-25 (25 Qs)"],
           ["Section 2","Phase I — Inpatient Rehabilitation","Q26-55 (30 Qs)"],
           ["Section 3","Phase II — Supervised Outpatient","Q56-100 (45 Qs)"],
           ["Section 4","Phase III & IV — Maintenance","Q101-115 (15 Qs)"],
           ["Section 5","Special Populations","Q116-130 (15 Qs)"],
           ["Section 6","Non-Exercise Components","Q131-145 (15 Qs)"],
           ["Section 7","Exercise Physiology & Parameters","Q146-165 (20 Qs)"],
           ["Section 8","Home-Based CR & Safety","Q166-175 (10 Qs)"],
           ["Section 9","Evidence & Outcomes","Q176-200 (25 Qs)"],
      ].map((row, ri) => new TableRow({ children: row.map(cell => new TableCell({
        shading: { type: ShadingType.SOLID, color: ri % 2 === 0 ? WHITE : GRAY_BG },
        children: [new Paragraph({ spacing: { before: 40, after: 40 }, alignment: AlignmentType.CENTER, children: [new TextRun({ text: cell, size: 18, color: DARK_TEXT, font: "Calibri" })] })],
      })) })),
    ],
    borders: {
      top: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      bottom: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      left: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      right: { style: BorderStyle.SINGLE, size: 4, color: MID_BLUE },
      insideH: { style: BorderStyle.SINGLE, size: 2, color: "BDC3C7" },
      insideV: { style: BorderStyle.SINGLE, size: 2, color: "BDC3C7" },
    },
  }),
  pageBreak(),
);

// Questions by section
sections.forEach(sec => {
  children.push(sectionHeader(sec.name, sec.color));
  children.push(spacer());
  const qs = mcqs.slice(sec.range[0], sec.range[1]);
  qs.forEach((m, i) => {
    buildQuestion(m, sec.range[0] + i).forEach(p => children.push(p));
  });
  children.push(pageBreak());
});

// Answer Key
children.push(
  new Paragraph({
    spacing: { before: 100, after: 120 },
    alignment: AlignmentType.CENTER,
    shading: { type: ShadingType.SOLID, color: "145A32" },
    children: [
      new TextRun({ text: "ANSWER KEY — ALL 200 QUESTIONS", bold: true, size: 32, color: WHITE, font: "Calibri", break: 1 }),
      new TextRun({ text: "Color coding:  Green = A  |  Blue = B  |  Yellow = C  |  Red = D", size: 18, color: "D5F5E3", font: "Calibri", break: 1 }),
    ],
  }),
  spacer(),
  buildAnswerTable(),
  spacer(),
  spacer(),
  // Section breakdown in answer key
  new Paragraph({ spacing: { before: 100, after: 60 }, children: [new TextRun({ text: "Correct Answers by Section:", bold: true, size: 20, color: DARK_BLUE, font: "Calibri" })] }),
  ...sections.map(sec => {
    const qs = mcqs.slice(sec.range[0], sec.range[1]);
    const answers = qs.map((m, i) => `Q${sec.range[0]+i+1}:${m.a}`).join("  |  ");
    return new Paragraph({
      spacing: { before: 40, after: 40 },
      shading: { type: ShadingType.SOLID, color: GRAY_BG },
      indent: { left: 180 },
      children: [
        new TextRun({ text: sec.name.split("(")[0].trim() + " — ", bold: true, size: 17, color: DARK_BLUE, font: "Calibri" }),
        new TextRun({ text: answers, size: 17, color: DARK_TEXT, font: "Calibri" }),
      ],
    });
  }),
  spacer(),
  new Paragraph({
    spacing: { before: 100, after: 60 },
    alignment: AlignmentType.CENTER,
    shading: { type: ShadingType.SOLID, color: GRAY_BG },
    indent: { left: 200, right: 200 },
    children: [
      new TextRun({ text: "This MCQ test is for educational purposes only. All clinical decisions must be based on individual patient assessment and current clinical guidelines.", size: 16, color: MID_TEXT, font: "Calibri", italics: true }),
    ],
  }),
);

// ─── Create document ──────────────────────────────────────────────────────────
const doc = new Document({
  styles: {
    default: {
      document: { run: { font: "Calibri", size: 19, color: DARK_TEXT } },
    },
  },
  sections: [{
    properties: {
      page: { margin: { top: 900, bottom: 900, left: 1000, right: 1000 } },
    },
    headers: {
      default: new Header({
        children: [new Paragraph({
          border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: MID_BLUE } },
          spacing: { before: 0, after: 80 },
          children: [
            new TextRun({ text: "Cardiac Rehabilitation: 200 MCQ Test  |  Phases & Exercise Progression", size: 15, color: MID_BLUE, font: "Calibri" }),
          ],
        })],
      }),
    },
    footers: {
      default: new Footer({
        children: [new Paragraph({
          border: { top: { style: BorderStyle.SINGLE, size: 6, color: MID_BLUE } },
          alignment: AlignmentType.RIGHT,
          spacing: { before: 60 },
          children: [
            new TextRun({ text: "Page ", size: 15, color: MID_BLUE, font: "Calibri" }),
            new TextRun({ children: [PageNumber.CURRENT], size: 15, color: MID_BLUE, font: "Calibri" }),
            new TextRun({ text: " of ", size: 15, color: MID_BLUE, font: "Calibri" }),
            new TextRun({ children: [PageNumber.TOTAL_PAGES], size: 15, color: MID_BLUE, font: "Calibri" }),
          ],
        })],
      }),
    },
    children,
  }],
});

Packer.toBuffer(doc).then(buf => {
  fs.writeFileSync("/home/daytona/workspace/cardiac-rehab-doc/Cardiac_Rehabilitation_200_MCQ_Test.docx", buf);
  console.log("MCQ document created successfully.");
});

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/cardiac-rehab-doc/mcq_generate.js'