const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Atrial Fibrillation - Comprehensive Seminar";
pres.author = "PG Medicine Resident";

// ─── COLOR PALETTE ───────────────────────────────────────────────────────────
const C = {
  navy:    "0D1B40",   // dominant dark bg
  red:     "C0392B",   // AF accent / danger
  teal:    "1A7F8E",   // section heading band
  lightB:  "D6EAF8",   // light blue box fill
  lightG:  "D5F5E3",   // light green box fill
  lightY:  "FEF9E7",   // light yellow box fill
  lightR:  "FADBD8",   // light red box fill
  white:   "FFFFFF",
  offW:    "F4F6F7",
  darkT:   "1B2631",
  gold:    "F0B429",
  gray:    "566573",
  lgray:   "ECF0F1",
};

// ─── HELPER: Add standard slide header bar ───────────────────────────────────
function addHeader(slide, title, sub) {
  // Top banner
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.navy } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.72, w: 10, h: 0.055, fill: { color: C.gold } });
  slide.addText(title.toUpperCase(), {
    x: 0.22, y: 0.05, w: 8.5, h: 0.62, margin: 0,
    fontSize: 21, bold: true, color: C.white, fontFace: "Calibri",
    charSpacing: 1.5
  });
  if (sub) {
    slide.addText(sub, {
      x: 0.22, y: 0.05, w: 8.5, h: 0.62, margin: 0,
      fontSize: 12, color: C.gold, fontFace: "Calibri", align: "right", valign: "bottom"
    });
  }
  // Source tag
  slide.addText("Reference: Harrison's Principles of Internal Medicine 22E", {
    x: 0, y: 5.42, w: 10, h: 0.21, margin: 0,
    fontSize: 7.5, color: C.gray, align: "right", fontFace: "Calibri",
    italic: true
  });
}

// ─── HELPER: Colored Box ────────────────────────────────────────────────────
function addBox(slide, x, y, w, h, fillColor, borderColor, text, txtSize, bold, txtColor) {
  slide.addShape(pres.ShapeType.roundRect, {
    x, y, w, h,
    fill: { color: fillColor },
    line: { color: borderColor || C.navy, width: 1.2 },
    rectRadius: 0.07
  });
  if (text) {
    slide.addText(text, {
      x: x + 0.06, y, w: w - 0.12, h,
      fontSize: txtSize || 11, bold: !!bold,
      color: txtColor || C.navy, fontFace: "Calibri",
      align: "center", valign: "middle", wrap: true, margin: 3
    });
  }
}

// ─── HELPER: Arrow ─────────────────────────────────────────────────────────
function addArrow(slide, x1, y1, x2, y2) {
  slide.addShape(pres.ShapeType.line, {
    x: x1, y: y1, w: x2 - x1, h: y2 - y1,
    line: { color: C.teal, width: 2, endArrowType: "triangle" }
  });
}

// ─── HELPER: Section label ──────────────────────────────────────────────────
function addSectionLabel(slide, label, x, y, w) {
  slide.addShape(pres.ShapeType.rect, {
    x, y, w: w || 2.8, h: 0.28,
    fill: { color: C.teal },
    line: { color: C.teal }
  });
  slide.addText(label, {
    x: x + 0.05, y, w: (w || 2.8) - 0.1, h: 0.28, margin: 0,
    fontSize: 9.5, bold: true, color: C.white, fontFace: "Calibri",
    align: "center", valign: "middle"
  });
}

// ─── HELPER: Bullet list ─────────────────────────────────────────────────────
function makeBullets(items, size, clr) {
  return items.map((item, i) => ({
    text: item,
    options: {
      bullet: { type: "bullet", characterCode: "25CF", indent: 14 },
      fontSize: size || 12.5,
      color: clr || C.navy,
      fontFace: "Calibri",
      breakLine: i < items.length - 1
    }
  }));
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navy } });
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 4.0, w: 10, h: 1.625, fill: { color: C.teal } });
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 3.88, w: 10, h: 0.13, fill: { color: C.gold } });

  // ECG line decoration (decorative zigzag using shapes)
  for (let i = 0; i < 10; i++) {
    sl.addShape(pres.ShapeType.line, {
      x: i * 1.0, y: 2.6, w: 0.3, h: 0,
      line: { color: "1A7F8E55", width: 1 }
    });
  }

  sl.addText("ATRIAL FIBRILLATION", {
    x: 0.5, y: 0.7, w: 9, h: 1.1,
    fontSize: 42, bold: true, color: C.white, fontFace: "Calibri",
    align: "center", charSpacing: 3
  });

  sl.addText("A Comprehensive Seminar for PG Medicine", {
    x: 0.5, y: 1.85, w: 9, h: 0.5,
    fontSize: 18, color: C.gold, fontFace: "Calibri", align: "center"
  });

  sl.addText("Definition  •  Epidemiology  •  Pathophysiology  •  Classification  •  Clinical Features\nECG Diagnosis  •  Risk Stratification  •  Rate & Rhythm Control  •  Anticoagulation  •  Ablation", {
    x: 0.5, y: 2.45, w: 9, h: 0.8,
    fontSize: 11.5, color: "A9CCE3", fontFace: "Calibri", align: "center"
  });

  sl.addText("Reference: Harrison's Principles of Internal Medicine, 22nd Edition (2025)", {
    x: 0.5, y: 4.15, w: 9, h: 0.35,
    fontSize: 11, color: C.white, fontFace: "Calibri", align: "center", italic: true
  });

  sl.addText("2023 ACC/AHA/ACCP/HRS Guidelines incorporated", {
    x: 0.5, y: 4.58, w: 9, h: 0.3,
    fontSize: 10, color: C.gold, fontFace: "Calibri", align: "center"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — DEFINITION & OVERVIEW
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Definition & Overview", "Slide 2 / 20");

  // Large definition box
  addBox(sl, 0.3, 0.9, 9.4, 1.1, C.navy, C.gold,
    "Atrial fibrillation (AF) is the most common SUSTAINED cardiac arrhythmia, characterized by chaotic rapid atrial electrical activity with ABSENT P waves and IRREGULAR R-R intervals on ECG.",
    13, true, C.white);

  // 4 key fact boxes
  const facts = [
    ["Most common\narrhythmia", C.lightB, C.teal],
    ["Atrial rate\n350–700 / min", C.lightG, "1E8449"],
    ["Ventricular rate\nirregularly irregular", C.lightY, "B7950B"],
    ["5× increased\nstroke risk", C.lightR, C.red],
  ];
  facts.forEach((f, i) => {
    addBox(sl, 0.22 + i * 2.4, 2.15, 2.25, 0.95, f[1], f[2], f[0], 12, true, C.darkT);
  });

  // Classification brief intro
  addSectionLabel(sl, "4-STAGE CONTINUUM (2023 ACC/AHA)", 0.3, 3.3, 4.5);
  const stages = [
    ["AT RISK", C.lightB, "0.30"],
    ["PRE-AF", C.lightG, "1.55"],
    ["AF", C.lightY, "2.80"],
    ["PERMANENT AF", C.lightR, "4.05"],
  ];
  stages.forEach(s => {
    addBox(sl, parseFloat(s[2]), 3.65, 1.15, 0.72, s[1], C.teal, s[0], 10, true, C.darkT);
    if (parseFloat(s[2]) < 4.05) {
      addArrow(sl, parseFloat(s[2]) + 1.15, 4.02, parseFloat(s[2]) + 1.55, 4.02);
    }
  });

  sl.addText("AF is a disease CONTINUUM, not just an arrhythmia. Prevention, screening & therapy required at each stage.", {
    x: 0.3, y: 4.5, w: 9.4, h: 0.45,
    fontSize: 11, color: C.teal, fontFace: "Calibri", bold: true, align: "center"
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — EPIDEMIOLOGY
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Epidemiology", "Slide 3 / 20");

  const stats = [
    ["~2–4%", "Prevalence in\ngeneral population"],
    ["~12%", "Prevalence in\nage ≥75 years"],
    ["~18%", "Prevalence in\nage ≥85 years"],
    ["~1/3", "AF patients\nare ≥80 years"],
  ];
  stats.forEach((s, i) => {
    sl.addShape(pres.ShapeType.rect, { x: 0.22 + i * 2.4, y: 0.88, w: 2.2, h: 1.15, fill: { color: C.navy }, line: { color: C.gold, width: 2 } });
    sl.addText(s[0], { x: 0.22 + i * 2.4, y: 0.92, w: 2.2, h: 0.58, fontSize: 28, bold: true, color: C.gold, fontFace: "Calibri", align: "center" });
    sl.addText(s[1], { x: 0.22 + i * 2.4, y: 1.5, w: 2.2, h: 0.5, fontSize: 10.5, color: C.white, fontFace: "Calibri", align: "center" });
  });

  addSectionLabel(sl, "COMORBIDITIES ASSOCIATED WITH AF", 0.3, 2.22, 5.5);
  const comor = ["Hypertension (most common)", "Coronary Heart Disease", "Obesity & Metabolic Syndrome", "Heart Failure (bidirectional)", "Sleep Apnea", "Hyperlipidemia", "Thyroid disease (hyperthyroid)", "Valvular disease (esp. Mitral Stenosis)"];
  sl.addText(makeBullets(comor.slice(0, 4), 11), { x: 0.3, y: 2.57, w: 4.4, h: 2.35, fontFace: "Calibri" });
  sl.addText(makeBullets(comor.slice(4), 11), { x: 4.9, y: 2.57, w: 4.8, h: 2.35, fontFace: "Calibri" });

  addSectionLabel(sl, "GENDER & AGE NOTE", 5.85, 2.22, 3.8);
  sl.addText("AF prevalence doubles every decade after age 50. More common in males, but women with AF have higher stroke risk and worse outcomes.", {
    x: 5.85, y: 2.57, w: 3.8, h: 1.0,
    fontSize: 10.5, color: C.darkT, fontFace: "Calibri", wrap: true
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — CLASSIFICATION
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Classification of Atrial Fibrillation", "Slide 4 / 20");

  // Classic classification
  addSectionLabel(sl, "TRADITIONAL CLASSIFICATION (Duration-Based)", 0.3, 0.85, 6.0);

  const trad = [
    ["PAROXYSMAL", "Self-terminating within 7 days\n(usually <48 h)\nMay recur", C.lightB, C.teal],
    ["PERSISTENT", "Lasts >7 days\nRequires cardioversion\n(elec. or pharmacologic)", C.lightY, "D4AC0D"],
    ["LONG-STANDING PERSISTENT", "Continuous AF >12 months;\nRhythm control still pursued", C.lightR, C.red],
    ["PERMANENT", "Accepted by patient & physician;\nNo further rhythm control", C.lgray, C.gray],
  ];
  trad.forEach((t, i) => {
    addBox(sl, 0.22 + i * 2.39, 1.2, 2.28, 1.45, t[2], t[3], `${t[0]}\n\n${t[1]}`, 9.5, false, C.darkT);
  });

  // New 4-stage classification
  addSectionLabel(sl, "NEW 4-STAGE CLASSIFICATION (ACC/AHA 2023) — Disease Continuum", 0.3, 2.88, 9.4);

  const newStages = [
    ["STAGE 1\nAt Risk for AF", "Risk factors: HTN, obesity,\nsleep apnea, smoking, alcohol\nNo AF yet — PREVENT", C.lightB, C.teal, "Prevention\nRisk factor\nmodification"],
    ["STAGE 2\nPre-AF", "Structural/electrical changes:\nAtrial enlargement, PACs,\nshort runs — Monitor closely", C.lightG, "1E8449", "Screening\nMonitoring"],
    ["STAGE 3\nAF", "Documented AF (paroxysmal,\npersistent, or long-standing)\nFull treatment required", C.lightY, "B7950B", "Rate control\nRhythm control\nAnticoagulation"],
    ["STAGE 4\nPermanent AF", "Accepted chronic AF; rhythm\ncontrol abandoned; focus\non rate + anticoagulation", C.lightR, C.red, "Rate control\nAnticoagulation\nQoL"],
  ];
  newStages.forEach((s, i) => {
    addBox(sl, 0.22 + i * 2.39, 3.22, 2.28, 1.58, s[2], s[3], `${s[0]}\n${s[1]}`, 8.5, false, C.darkT);
    addBox(sl, 0.22 + i * 2.39, 4.87, 2.28, 0.52, s[3], s[3], s[4], 8, true, C.white);
    if (i < 3) addArrow(sl, 0.22 + i * 2.39 + 2.28, 4.0, 0.22 + (i + 1) * 2.39, 4.0);
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Pathophysiology", "Slide 5 / 20");

  // Left column: Triggers
  addSectionLabel(sl, "TRIGGERS", 0.25, 0.85, 2.9);
  addBox(sl, 0.25, 1.18, 2.9, 1.8, C.lightB, C.teal,
    "• Pulmonary vein ectopy\n  (primary source)\n• PACs triggering reentry\n• Autonomic changes\n• Electrolyte imbalance\n• Alcohol (holiday heart)", 10.5, false, C.darkT);

  // Middle: Substrate
  addSectionLabel(sl, "SUBSTRATE", 3.35, 0.85, 3.3);
  addBox(sl, 3.35, 1.18, 3.3, 1.8, C.lightY, "B7950B",
    "• Atrial fibrosis & structural remodeling\n• Shortened atrial refractory periods\n  (electrical remodeling)\n• Conduction heterogeneity\n• Increased atrial size / dilation\n• Age-related changes", 10.5, false, C.darkT);

  // Right: Perpetuators
  addSectionLabel(sl, "PERPETUATORS", 6.85, 0.85, 2.9);
  addBox(sl, 6.85, 1.18, 2.9, 1.8, C.lightR, C.red,
    "• Autonomic imbalance\n• Inflammation\n  (CRP, IL-6 elevated)\n• Oxidative stress\n• Valvular disease\n• Elevated filling pressure", 10.5, false, C.darkT);

  // Main mechanism box
  addSectionLabel(sl, "MECHANISM: MULTIPLE WAVELET REENTRY", 0.25, 3.1, 5.5);
  addBox(sl, 0.25, 3.42, 5.5, 1.65, C.lightG, "1E8449",
    "Multiple simultaneous wavelets of depolarization circulate chaotically through the atria, perpetuated by short refractory periods and slow/inhomogeneous conduction. No single stable reentrant circuit — hence 'fibrillation'.\n\nPulmonary vein isolation (PVI) is the cornerstone of ablation based on this mechanism.", 10.5, false, C.darkT);

  // Key concept box right
  addSectionLabel(sl, "KEY CONCEPT: AF BEGETS AF", 5.95, 3.1, 3.8);
  addBox(sl, 5.95, 3.42, 3.8, 1.65, C.lightR, C.red,
    "Prolonged AF causes progressive electrical & structural atrial remodeling → lowers threshold for AF → makes AF harder to terminate and maintain sinus rhythm. This is the basis for early rhythm control!", 10.5, false, C.darkT);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — RISK FACTORS & LIFESTYLE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Risk Factors & Lifestyle Impact", "Slide 6 / 20");

  addSectionLabel(sl, "MODIFIABLE RISK FACTORS", 0.25, 0.85, 4.6);
  const modRF = [
    ["Obesity\n(BMI > 30)", C.lightR, C.red],
    ["Hypertension\n(most common)", C.lightB, C.teal],
    ["Smoking", C.lightY, "B7950B"],
    ["Alcohol", C.lightR, C.red],
  ];
  const modRF2 = [
    ["Sleep Apnea\n(OSA)", C.lightG, "1E8449"],
    ["Physical\nInactivity", C.lightB, C.teal],
    ["Diabetes\nMellitus", C.lightY, "B7950B"],
    ["Stress /\nPsychological", C.lightR, C.red],
  ];
  modRF.forEach((r, i) => addBox(sl, 0.25 + i * 1.15, 1.2, 1.08, 0.8, r[1], r[2], r[0], 9, true, C.darkT));
  modRF2.forEach((r, i) => addBox(sl, 0.25 + i * 1.15, 2.08, 1.08, 0.8, r[1], r[2], r[0], 9, true, C.darkT));

  addSectionLabel(sl, "NON-MODIFIABLE", 4.95, 0.85, 2.5);
  sl.addText(makeBullets(["Increasing age", "Male sex", "Family history / Genetics", "Structural heart disease", "Congenital heart disease"], 10.5), {
    x: 4.95, y: 1.2, w: 2.5, h: 1.65, fontFace: "Calibri"
  });

  addSectionLabel(sl, "EXERCISE & AF RISK", 7.55, 0.85, 2.2);
  addBox(sl, 7.55, 1.2, 2.2, 1.65, C.lightY, "B7950B",
    "MALES: U-shaped curve\n• Very low exercise → ↑AF\n• Extreme endurance → ↑AF\n• Moderate = lowest risk\n\nFEMALES: Linear — more exercise = less AF", 9.5, false, C.darkT);

  addSectionLabel(sl, "IMPORTANT NOTE ON CAFFEINE", 0.25, 3.0, 4.5);
  addBox(sl, 0.25, 3.33, 4.5, 0.9, C.lightG, "1E8449",
    "Large cohort studies show MODEST CAFFEINE INTAKE is associated with a DECREASED risk of AF — contrary to popular belief. Caffeine restriction is NOT routinely recommended.", 10.5, false, C.darkT);

  addSectionLabel(sl, "UPSTREAM THERAPY PRINCIPLE", 5.0, 3.0, 4.75);
  addBox(sl, 5.0, 3.33, 4.75, 0.9, C.lightB, C.teal,
    "Aggressive treatment of modifiable risk factors (weight loss, BP control, OSA treatment, alcohol reduction) can SUBSTANTIALLY reduce AF episodes — this is 'Upstream Therapy' and is a Class I recommendation.", 10.5, false, C.darkT);

  addBox(sl, 0.25, 4.32, 9.5, 0.68, C.navy, C.gold,
    "KEY MESSAGE: AF management is not just drugs and procedures — lifestyle modification is a cornerstone of treatment!", 11.5, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — CLINICAL FEATURES & SYMPTOMS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Clinical Features & Presentation", "Slide 7 / 20");

  addSectionLabel(sl, "SYMPTOMS (Variable — can be asymptomatic!)", 0.25, 0.85, 6.5);
  const symptoms = [
    ["Palpitations", "Most common in young;\nless prominent in elderly", C.lightB, C.teal],
    ["Dyspnea /\nBreathlessness", "Exertional or rest;\ndue to rate + loss of AV sync", C.lightY, "B7950B"],
    ["Fatigue /\nExercise intolerance", "Reduced cardiac output;\ntachycardia-mediated", C.lightG, "1E8449"],
    ["Chest discomfort", "May indicate ischemia\nor rate-related pain", C.lightR, C.red],
    ["Dizziness /\nLight-headedness", "Reduced cerebral flow;\ncommon in elderly", C.lightB, C.teal],
  ];
  symptoms.forEach((s, i) => {
    addBox(sl, 0.22 + i * 1.91, 1.18, 1.84, 1.2, s[2], s[3], `${s[0]}\n\n${s[1]}`, 9, false, C.darkT);
  });

  addSectionLabel(sl, "SERIOUS PRESENTATIONS", 0.25, 2.57, 4.5);
  const serious = [
    "Acute pulmonary edema — abrupt loss of atrial kick in stiff LV",
    "Stroke / TIA — first presentation in up to 15-20% of cases",
    "Syncope / Fall (esp. in elderly) — reduced cardiac output",
    "Tachycardia-induced cardiomyopathy — prolonged rapid rates → dilated CMP",
  ];
  sl.addText(makeBullets(serious, 10.5, C.red), { x: 0.25, y: 2.9, w: 4.5, h: 1.85, fontFace: "Calibri" });

  addSectionLabel(sl, "PHYSICAL EXAMINATION", 4.9, 2.57, 4.85);
  const exam = [
    "Irregularly irregular pulse — hallmark finding",
    "Pulse deficit (apical > radial rate)",
    "Variation in S1 intensity",
    "Absent a-wave in JVP",
    "Signs of heart failure (crepitations, raised JVP, edema)",
    "Signs of underlying cause (thyroid, valvular)",
  ];
  sl.addText(makeBullets(exam, 10.5), { x: 4.9, y: 2.9, w: 4.85, h: 1.85, fontFace: "Calibri" });

  addBox(sl, 0.25, 4.82, 9.5, 0.48, C.teal, C.teal,
    "IMPORTANT: In elderly patients — palpitations are LESS prominent; AF may present as syncope, fall, stroke, or cognitive decline!", 11, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — ECG DIAGNOSIS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "ECG Diagnosis of AF", "Slide 8 / 20");

  // Main ECG features box
  addSectionLabel(sl, "CLASSIC ECG FEATURES OF AF", 0.25, 0.85, 5.5);

  const ecgFeatures = [
    ["1. ABSENT P WAVES", "No discrete P waves; replaced by chaotic fibrillatory (f) waves at 350-700/min", C.lightR, C.red],
    ["2. IRREGULAR R-R INTERVALS", "Ventricular response is \"irregularly irregular\" — hallmark feature on ECG", C.lightB, C.teal],
    ["3. FIBRILLATORY BASELINE", "Fine or coarse oscillations replacing isoelectric baseline; best seen in V1, II", C.lightY, "B7950B"],
    ["4. NORMAL QRS MORPHOLOGY", "QRS usually narrow (unless BBB, WPW, or aberrancy present)", C.lightG, "1E8449"],
  ];
  ecgFeatures.forEach((f, i) => {
    addBox(sl, 0.25, 1.18 + i * 0.95, 9.5, 0.88, f[2], f[3], `${f[0]}:  ${f[1]}`, 11, false, C.darkT);
  });

  addSectionLabel(sl, "SPECIAL ECG PATTERNS", 0.25, 5.0, 4.5);
  sl.addText("• COARSE AF: larger f waves — suggests ↑atrial pressure or recent onset\n• FINE AF: smaller f waves — suggests long-standing AF or dilated atria\n• WPW + AF: Irregular WIDE complex with delta waves — DANGEROUS! Rate can exceed 300/min → VF", {
    x: 0.25, y: 5.0, w: 9.5, h: 0.5,
    fontSize: 9.5, color: C.navy, fontFace: "Calibri"
  });
  // This slide is compact with 4 boxes + footer note
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — INVESTIGATIONS & WORKUP
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Investigations & Initial Workup", "Slide 9 / 20");

  addSectionLabel(sl, "MANDATORY INVESTIGATIONS", 0.25, 0.85, 4.6);
  const mandatory = [
    "12-lead ECG — confirm AF, assess rate, look for ischemia / WPW",
    "Echocardiogram (Echo) — LV function, valve disease, LA size, thrombus",
    "Thyroid function tests (TFTs) — hyperthyroidism triggers AF",
    "Complete Blood Count (CBC) — anemia, infection",
    "Renal function, electrolytes — for drug dosing, rate control",
    "Liver function tests — warfarin / amiodarone dosing",
    "INR / coagulation — if starting anticoagulation",
    "Blood glucose / HbA1c — metabolic assessment",
  ];
  sl.addText(makeBullets(mandatory, 11), { x: 0.25, y: 1.18, w: 4.6, h: 3.6, fontFace: "Calibri" });

  addSectionLabel(sl, "ADDITIONAL / SELECTIVE INVESTIGATIONS", 5.05, 0.85, 4.7);
  const additional = [
    "Holter monitoring / Ambulatory ECG — for paroxysmal AF detection",
    "Event recorder / Loop recorder — if symptoms infrequent",
    "Exercise stress test — if rate control adequacy suspected",
    "Cardiac MRI — atrial fibrosis assessment pre-ablation",
    "Transesophageal Echo (TEE) — rule out LA appendage thrombus before cardioversion",
    "CT angiography (delayed) — LA thrombus with high sensitivity",
    "Sleep study (polysomnography) — if OSA suspected",
    "Chest X-ray — cardiomegaly, pulmonary edema",
  ];
  sl.addText(makeBullets(additional, 11), { x: 5.05, y: 1.18, w: 4.7, h: 3.6, fontFace: "Calibri" });

  addBox(sl, 0.25, 4.92, 9.5, 0.48, C.teal, C.teal,
    "TEE or cardiac CT is required before cardioversion if AF duration >48 h or unknown, to exclude LA appendage thrombus!", 11, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — THROMBOEMBOLIC RISK (CHA2DS2-VASc)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Thromboembolic Risk — CHA₂DS₂-VASc Score", "Slide 10 / 20");

  // Score table
  addSectionLabel(sl, "CHA₂DS₂-VASc SCORING", 0.25, 0.85, 5.5);

  const rows = [
    ["C", "Congestive Heart Failure", "1"],
    ["H", "Hypertension", "1"],
    ["A₂", "Age ≥ 75 years", "2"],
    ["D", "Diabetes Mellitus", "1"],
    ["S₂", "Stroke / TIA / thromboembolism (prior)", "2"],
    ["V", "Vascular disease (MI, PAD, aortic plaque)", "1"],
    ["A", "Age 65–74 years", "1"],
    ["Sc", "Sex category (Female)", "1"],
  ];

  // Table header
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.18, w: 5.5, h: 0.32, fill: { color: C.navy } });
  sl.addText("Letter  |  Risk Factor  |  Score", { x: 0.3, y: 1.18, w: 5.4, h: 0.32, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });

  rows.forEach((r, i) => {
    const fill = i % 2 === 0 ? C.lightB : C.white;
    sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.5 + i * 0.34, w: 5.5, h: 0.34, fill: { color: fill }, line: { color: "BFC9CA", width: 0.5 } });
    sl.addText(r[0], { x: 0.3, y: 1.5 + i * 0.34, w: 0.5, h: 0.34, fontSize: 11, bold: true, color: C.teal, fontFace: "Calibri", valign: "middle" });
    sl.addText(r[1], { x: 0.85, y: 1.5 + i * 0.34, w: 4.1, h: 0.34, fontSize: 10.5, color: C.darkT, fontFace: "Calibri", valign: "middle" });
    sl.addText(r[2], { x: 5.0, y: 1.5 + i * 0.34, w: 0.75, h: 0.34, fontSize: 12, bold: true, color: C.red, fontFace: "Calibri", align: "center", valign: "middle" });
  });
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 4.22, w: 5.5, h: 0.32, fill: { color: C.gold } });
  sl.addText("MAXIMUM SCORE = 9", { x: 0.3, y: 4.22, w: 5.4, h: 0.32, fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri", align: "center", valign: "middle" });

  // Right: interpretation + anticoagulation decision
  addSectionLabel(sl, "ANTICOAGULATION DECISION", 6.0, 0.85, 3.75);
  const decisions = [
    ["Score 0\n(Male)", "No anticoagulation\nneeded", C.lightG, "1E8449"],
    ["Score 1\n(Male)", "Consider OAC\n(individualize)", C.lightY, "B7950B"],
    ["Score ≥ 2\n(Male)\nScore ≥ 1\n(Female)", "ANTICOAGULATION\nRECOMMENDED\n(Class I)", C.lightR, C.red],
  ];
  decisions.forEach((d, i) => addBox(sl, 6.0, 1.18 + i * 1.07, 3.75, 1.0, d[2], d[3], `${d[0]}\n→ ${d[1]}`, 10, true, C.darkT));

  addBox(sl, 6.0, 4.4, 3.75, 0.62, C.navy, C.gold,
    "All patients ≥75 yrs have CHA₂DS₂-VASc ≥2 automatically — anticoagulate regardless of AF type!", 10, true, C.white);

  addBox(sl, 0.25, 4.62, 5.5, 0.62, C.teal, C.teal,
    "Nonvalvular AF: 5× increased stroke risk. Valvular AF (MS, mechanical valve): always anticoagulate!", 10.5, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — BLEEDING RISK (HAS-BLED)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Bleeding Risk — HAS-BLED Score", "Slide 11 / 20");

  addSectionLabel(sl, "HAS-BLED SCORING SYSTEM", 0.25, 0.85, 5.5);

  const hasbled = [
    ["H", "Hypertension (uncontrolled, SBP >160)", "1"],
    ["A", "Abnormal renal / liver function", "1 each (max 2)"],
    ["S", "Stroke history", "1"],
    ["B", "Bleeding history or predisposition", "1"],
    ["L", "Labile INR (if on warfarin, TTR <60%)", "1"],
    ["E", "Elderly (age >65 years)", "1"],
    ["D", "Drugs (antiplatelet, NSAIDs) or alcohol", "1 each (max 2)"],
  ];

  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.18, w: 5.5, h: 0.3, fill: { color: C.navy } });
  sl.addText("Factor  |  Definition  |  Points", { x: 0.3, y: 1.18, w: 5.4, h: 0.3, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  hasbled.forEach((h, i) => {
    sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.48 + i * 0.38, w: 5.5, h: 0.38, fill: { color: i % 2 === 0 ? C.lightR : C.white }, line: { color: "BFC9CA", width: 0.5 } });
    sl.addText(h[0], { x: 0.3, y: 1.48 + i * 0.38, w: 0.4, h: 0.38, fontSize: 11, bold: true, color: C.red, fontFace: "Calibri", valign: "middle" });
    sl.addText(h[1], { x: 0.76, y: 1.48 + i * 0.38, w: 3.8, h: 0.38, fontSize: 10, color: C.darkT, fontFace: "Calibri", valign: "middle" });
    sl.addText(h[2], { x: 4.6, y: 1.48 + i * 0.38, w: 1.15, h: 0.38, fontSize: 10, bold: true, color: C.red, fontFace: "Calibri", align: "center", valign: "middle" });
  });

  // Right panel
  addSectionLabel(sl, "INTERPRETATION", 5.95, 0.85, 3.8);
  const interp = [
    ["0–2", "Low bleeding risk\nAnticoagulate", C.lightG, "1E8449"],
    ["3", "Moderate risk\nCaution, review modifiable factors", C.lightY, "B7950B"],
    ["≥ 4", "High risk\nNOT a contraindication — correct modifiable factors!", C.lightR, C.red],
  ];
  interp.forEach((it, i) => addBox(sl, 5.95, 1.18 + i * 0.9, 3.8, 0.84, it[2], it[3], `Score ${it[0]}:  ${it[1]}`, 10, false, C.darkT));

  addBox(sl, 5.95, 3.9, 3.8, 0.62, C.teal, C.teal,
    "HAS-BLED is NOT used to withhold anticoagulation — it identifies CORRECTABLE risk factors (e.g., uncontrolled BP, NSAIDs, alcohol).", 9.5, true, C.white);

  addSectionLabel(sl, "MODIFIABLE HAS-BLED FACTORS TO CORRECT", 0.25, 4.12, 5.5);
  sl.addText("• Control BP  • Reduce alcohol  • Stop NSAIDs/antiplatelets  • Correct anaemia  • Stabilize INR (or switch to DOAC)", {
    x: 0.25, y: 4.45, w: 5.5, h: 0.55,
    fontSize: 10.5, color: C.darkT, fontFace: "Calibri"
  });

  addBox(sl, 0.25, 5.05, 9.5, 0.38, C.navy, C.gold,
    "KEY PRINCIPLE: Net clinical benefit of anticoagulation almost always outweighs bleeding risk in high-stroke-risk patients!", 10.5, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — OVERVIEW OF MANAGEMENT
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Overview of Management — 3 Pillars", "Slide 12 / 20");

  // Three pillars
  const pillars = [
    ["PILLAR 1\nSYMPTOM CONTROL", "Rate Control\n+\nRhythm Control", C.navy, C.gold, "Rate-lowering drugs,\ncardioversion, ablation"],
    ["PILLAR 2\nSTROKE PREVENTION", "Anticoagulation\n(CHA₂DS₂-VASc guided)", C.teal, C.white, "Warfarin / DOACs,\nWatchman device"],
    ["PILLAR 3\nRISK FACTOR MODIFICATION", "Upstream Therapy\n+\nLifestyle Modification", C.red, C.white, "Weight loss, BP control,\nOSA, alcohol, exercise"],
  ];
  pillars.forEach((p, i) => {
    sl.addShape(pres.ShapeType.rect, { x: 0.25 + i * 3.17, y: 0.88, w: 3.0, h: 0.85, fill: { color: p[2] }, line: { color: p[3], width: 2 } });
    sl.addText(p[0], { x: 0.25 + i * 3.17, y: 0.88, w: 3.0, h: 0.85, fontSize: 12, bold: true, color: p[3], fontFace: "Calibri", align: "center", valign: "middle" });
    addBox(sl, 0.25 + i * 3.17, 1.8, 3.0, 0.72, C.lightB, p[2], p[1], 11, true, C.darkT);
    addBox(sl, 0.25 + i * 3.17, 2.6, 3.0, 0.65, C.white, p[2], p[4], 10, false, C.darkT);
  });

  // Acute Management Flowchart
  addSectionLabel(sl, "ACUTE MANAGEMENT FLOWCHART", 0.25, 3.38, 9.5);

  addBox(sl, 0.25, 3.72, 9.5, 0.48, C.navy, C.navy, "NEW ONSET AF — Is patient HEMODYNAMICALLY UNSTABLE?  (Hypotension, pulm. edema, acute ischemia)", 11, true, C.white);
  addArrow(sl, 2.2, 4.2, 2.2, 4.52);
  addArrow(sl, 7.5, 4.2, 7.5, 4.52);

  addBox(sl, 0.25, 4.52, 4.1, 0.72, C.lightR, C.red, "YES → EMERGENT ELECTRICAL\nCARDIOVERSION\n(QRS-synchronized DC shock)", 10.5, true, C.red);
  addBox(sl, 4.5, 4.52, 5.25, 0.72, C.lightG, "1E8449", "NO → Rate control first → Consider anticoagulation → Assess rhythm control strategy → Evaluate/correct risk factors", 10, false, C.darkT);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 — RATE CONTROL
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Rate Control Strategy", "Slide 13 / 20");

  addSectionLabel(sl, "RATE CONTROL TARGETS", 0.25, 0.85, 3.2);
  addBox(sl, 0.25, 1.18, 3.2, 1.08, C.lightB, C.teal,
    "LENIENT: HR < 110 bpm at rest\n(preferred if asymptomatic)\n\nSTRICT: HR < 80 bpm at rest\n(if symptomatic or LV dysfunction)", 10.5, false, C.darkT);

  addSectionLabel(sl, "RATE CONTROL DRUGS", 3.65, 0.85, 6.1);

  const drugs = [
    ["BETA-BLOCKERS\n(1st line)", "Metoprolol, Bisoprolol, Carvedilol\n• Best for high sympathetic tone\n• Safe in HF with EF (HFrEF)\n• Avoid in acute decompensation, severe asthma", C.lightB, C.teal],
    ["NON-DIHYDROPYRIDINE\nCCBs", "Verapamil, Diltiazem\n• Effective rate control\n• CONTRAINDICATED in HFrEF!\n• Avoid in decompensated HF, WPW", C.lightY, "B7950B"],
    ["DIGOXIN", "0.125–0.25 mg daily\n• Add-on in HFrEF or hypotension\n• Poor rate control with exercise\n• Monitor toxicity (narrow TI)", C.lightG, "1E8449"],
    ["AMIODARONE\n(rescue / ICU)", "IV amiodarone for rate control\nwhen other drugs fail or contraindicated\n• Multiple side effects (chronic use)", C.lightR, C.red],
  ];
  drugs.forEach((d, i) => {
    addBox(sl, 3.65 + (i % 2) * 3.05, 1.18 + Math.floor(i / 2) * 1.45, 2.98, 1.38, d[2], d[3], `${d[0]}\n${d[1]}`, 9, false, C.darkT);
  });

  addSectionLabel(sl, "SPECIAL SITUATIONS IN RATE CONTROL", 0.25, 3.56, 9.5);
  const special = [
    ["WPW + AF", "AVOID AV nodal blockers (digoxin, CCB, beta-blockers)\nUse Procainamide / Ibutilide / Electrical cardioversion → Ablation", C.lightR, C.red],
    ["Pre-excited AF", "Wide complex irregular tachycardia >250/min → can cause VF\nIV Procainamide; Emergency cardioversion if hemodynamically unstable", C.lightR, C.red],
  ];
  special.forEach((s, i) => addBox(sl, 0.25 + i * 4.88, 3.9, 4.7, 0.88, s[2], s[3], `${s[0]}: ${s[1]}`, 9.5, false, C.darkT));

  addBox(sl, 0.25, 4.88, 9.5, 0.42, C.navy, C.gold,
    "Rate control alone (vs rhythm control) has NOT been shown to be inferior for mortality in stable patients — AFFIRM Trial", 10.5, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 — RHYTHM CONTROL & CARDIOVERSION
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Rhythm Control & Cardioversion", "Slide 14 / 20");

  addSectionLabel(sl, "WHEN TO PURSUE RHYTHM CONTROL", 0.25, 0.85, 5.5);
  const indications = [
    "Persistent or bothersome symptoms despite rate control",
    "Young patients with first presentation",
    "Tachycardia-induced cardiomyopathy (reversible with rhythm control)",
    "AF in structurally normal heart",
    "Difficulty achieving adequate rate control",
    "Patient preference",
    "EARLY RHYTHM CONTROL (EAST-AFNET 4): reduces cardiovascular events if initiated within 1 year of AF diagnosis",
  ];
  sl.addText(makeBullets(indications, 10.5), { x: 0.25, y: 1.18, w: 5.5, h: 2.75, fontFace: "Calibri" });

  addSectionLabel(sl, "PHARMACOLOGIC CARDIOVERSION", 5.95, 0.85, 3.8);
  addBox(sl, 5.95, 1.18, 3.8, 1.55, C.lightB, C.teal,
    "IBUTILIDE (IV) — Class III\n• Most effective for acute conversion\n• Risk: Torsades de Pointes\n• AVOID: prolonged QT, severe LV dysfunction\n\nFlecainide / Propafenone — Pill-in-pocket\n• Only in structurally normal heart\n• Patient self-administers at onset of AF", 9.5, false, C.darkT);

  addSectionLabel(sl, "ELECTRICAL CARDIOVERSION", 5.95, 2.83, 3.8);
  addBox(sl, 5.95, 3.16, 3.8, 0.9, C.lightY, "B7950B",
    "QRS-synchronized DC shock (100–200 J biphasic)\nSedate patient first\nIf AF >48h or unknown: TEE/anticoag. before CV\nMust anticoagulate 4 weeks AFTER CV (atrial stunning)", 9.5, false, C.darkT);

  // Anticoag around CV flowchart
  addSectionLabel(sl, "ANTICOAGULATION AROUND CARDIOVERSION", 0.25, 4.15, 5.5);
  addBox(sl, 0.25, 4.48, 2.55, 0.78, C.lightG, "1E8449", "AF < 48h\nAnticoagulate &\nCardiovert immediately", 9.5, false, C.darkT);
  addBox(sl, 2.95, 4.48, 2.8, 0.78, C.lightR, C.red, "AF > 48h or unknown\nTEE to exclude LA thrombus\nOR anticoag. ≥3 weeks, then CV", 9.5, false, C.darkT);
  addBox(sl, 0.25, 4.48, 5.5, 0.78, C.white, C.white, "", 9); // spacer
  // redo the boxes without overlap
  sl.addShape(pres.ShapeType.roundRect, { x: 0.25, y: 4.48, w: 2.55, h: 0.78, fill: { color: C.lightG }, line: { color: "1E8449", width: 1 }, rectRadius: 0.07 });
  sl.addText("AF < 48h\nAnticoagulate &\nCardiovert soon", { x: 0.25, y: 4.48, w: 2.55, h: 0.78, fontSize: 9.5, color: C.darkT, fontFace: "Calibri", align: "center", valign: "middle" });
  sl.addShape(pres.ShapeType.roundRect, { x: 3.0, y: 4.48, w: 2.7, h: 0.78, fill: { color: C.lightR }, line: { color: C.red, width: 1 }, rectRadius: 0.07 });
  sl.addText("AF > 48h or UNKNOWN\nTEE or ≥3wk anticoag\nthen cardioversion", { x: 3.0, y: 4.48, w: 2.7, h: 0.78, fontSize: 9.5, color: C.darkT, fontFace: "Calibri", align: "center", valign: "middle" });
  sl.addShape(pres.ShapeType.roundRect, { x: 5.85, y: 4.48, w: 3.9, h: 0.78, fill: { color: C.navy }, line: { color: C.gold, width: 1 }, rectRadius: 0.07 });
  sl.addText("BOTH: Anticoagulate ≥4 weeks AFTER cardioversion (atrial stunning!) — then reassess CHA₂DS₂-VASc", { x: 5.85, y: 4.48, w: 3.9, h: 0.78, fontSize: 9.5, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 15 — ANTIARRHYTHMIC DRUGS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Antiarrhythmic Drugs for Rhythm Control", "Slide 15 / 20");

  addSectionLabel(sl, "CHOICE OF AAD BASED ON CARDIAC SUBSTRATE", 0.25, 0.85, 9.5);

  const aadRows = [
    { drug: "Flecainide\n(Class IC)", use: "No structural heart disease (SHD)", dose: "100–150 mg BD", key: "AVOID in CAD, HF, WPW; most effective in normal heart", fill: C.lightG, border: "1E8449" },
    { drug: "Propafenone\n(Class IC)", use: "No structural heart disease", dose: "150–300 mg TDS", key: "AVOID in SHD; minor beta-blocking effect; same as flecainide", fill: C.lightG, border: "1E8449" },
    { drug: "Sotalol\n(Class III)", use: "CAD, mild LVH (EF >40%)", dose: "80–160 mg BD", key: "QT monitoring essential; prolongs QT → TdP risk; also beta-blocker", fill: C.lightY, border: "B7950B" },
    { drug: "Dronedarone\n(Class III)", use: "Non-permanent AF, no severe HF", dose: "400 mg BD", key: "AVOID in permanent AF, severe HF; ↓hospitalization; monitor liver", fill: C.lightY, border: "B7950B" },
    { drug: "Amiodarone\n(Class III)", use: "Any structural disease, HFrEF", dose: "200 mg OD (maintenance)", key: "Most effective AAD; MULTIPLE toxicities (thyroid, pulm, liver, cornea, skin); last resort", fill: C.lightR, border: C.red },
    { drug: "Dofetilide\n(Class III)", use: "HF, CAD", dose: "Renal dose-adjusted", key: "Torsades risk — in-hospital initiation required; rarely used", fill: C.lightR, border: C.red },
  ];

  // Table headers
  sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.18, w: 9.5, h: 0.3, fill: { color: C.navy } });
  ["Drug (Class)", "Indication", "Dose", "Key Points"].forEach((h, i) => {
    const widths = [1.9, 2.0, 1.5, 4.1];
    const xpos = [0.28, 2.18, 4.18, 5.68];
    sl.addText(h, { x: xpos[i], y: 1.18, w: widths[i], h: 0.3, fontSize: 9.5, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  });

  aadRows.forEach((r, i) => {
    sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.48 + i * 0.53, w: 9.5, h: 0.53, fill: { color: r.fill }, line: { color: "BFC9CA", width: 0.5 } });
    sl.addText(r.drug, { x: 0.28, y: 1.48 + i * 0.53, w: 1.9, h: 0.53, fontSize: 9.5, bold: true, color: r.border, fontFace: "Calibri", valign: "middle" });
    sl.addText(r.use, { x: 2.18, y: 1.48 + i * 0.53, w: 2.0, h: 0.53, fontSize: 9, color: C.darkT, fontFace: "Calibri", valign: "middle", wrap: true });
    sl.addText(r.dose, { x: 4.18, y: 1.48 + i * 0.53, w: 1.5, h: 0.53, fontSize: 9, color: C.darkT, fontFace: "Calibri", valign: "middle" });
    sl.addText(r.key, { x: 5.68, y: 1.48 + i * 0.53, w: 4.07, h: 0.53, fontSize: 8.5, color: C.darkT, fontFace: "Calibri", valign: "middle", wrap: true });
  });

  addBox(sl, 0.25, 4.7, 9.5, 0.65, C.navy, C.gold,
    "RULE: In structural heart disease (HFrEF/CAD), use Amiodarone or Dofetilide.\nIn no SHD: Flecainide or Propafenone preferred (most effective, best tolerated).", 10, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 16 — ANTICOAGULATION: WARFARIN vs DOACs
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Anticoagulation — Warfarin vs DOACs", "Slide 16 / 20");

  addSectionLabel(sl, "WARFARIN", 0.25, 0.85, 4.6);
  const warfPoints = [
    "Vitamin K antagonist — inhibits Factors II, VII, IX, X",
    "Target INR: 2–3 (2–2.5 in elderly)",
    "Requires regular INR monitoring (monthly)",
    "Multiple drug & food interactions (dietary Vit K)",
    "Dose 2–5 mg/day (lower in elderly)",
    "Risk of osteoporosis with long-term use",
    "INDICATED in mechanical valves & Mitral Stenosis (moderate-severe)",
  ];
  sl.addText(makeBullets(warfPoints, 10), { x: 0.25, y: 1.18, w: 4.6, h: 2.75, fontFace: "Calibri" });

  addSectionLabel(sl, "DOACs (PREFERRED in non-valvular AF)", 5.05, 0.85, 4.7);
  const doacTable = [
    ["Dabigatran", "Direct thrombin inhibitor", "150 mg BD (110 mg BD if >80 yrs)"],
    ["Rivaroxaban", "Factor Xa inhibitor", "20 mg OD with evening meal"],
    ["Apixaban", "Factor Xa inhibitor", "5 mg BD (2.5 mg BD if ≥2 criteria*)"],
    ["Edoxaban", "Factor Xa inhibitor", "60 mg OD (30 mg if CrCl 15-50)"],
  ];
  sl.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.18, w: 4.7, h: 0.28, fill: { color: C.teal } });
  sl.addText("Drug  |  Mechanism  |  Dose", { x: 5.1, y: 1.18, w: 4.6, h: 0.28, fontSize: 9, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  doacTable.forEach((d, i) => {
    sl.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.46 + i * 0.42, w: 4.7, h: 0.42, fill: { color: i % 2 === 0 ? C.lightB : C.white }, line: { color: "BFC9CA", width: 0.5 } });
    sl.addText(d[0], { x: 5.08, y: 1.46 + i * 0.42, w: 1.2, h: 0.42, fontSize: 9, bold: true, color: C.teal, fontFace: "Calibri", valign: "middle" });
    sl.addText(d[1], { x: 6.3, y: 1.46 + i * 0.42, w: 1.5, h: 0.42, fontSize: 8.5, color: C.darkT, fontFace: "Calibri", valign: "middle" });
    sl.addText(d[2], { x: 7.82, y: 1.46 + i * 0.42, w: 1.93, h: 0.42, fontSize: 8.5, color: C.darkT, fontFace: "Calibri", valign: "middle", wrap: true });
  });
  sl.addText("*Apixaban dose reduction: ≥2 of: age ≥80, weight ≤60kg, creatinine ≥1.5 mg/dL", {
    x: 5.05, y: 3.15, w: 4.7, h: 0.28, fontSize: 8, color: C.gray, fontFace: "Calibri", italic: true
  });

  addSectionLabel(sl, "DOACs vs WARFARIN — KEY ADVANTAGES", 5.05, 3.48, 4.7);
  const doacAdv = ["No routine monitoring needed", "Fewer drug interactions", "No dietary restrictions", "Similar or better stroke prevention", "Similar or LESS bleeding (especially ICH)", "Rapid onset and offset"];
  sl.addText(makeBullets(doacAdv, 9.5), { x: 5.05, y: 3.78, w: 4.7, h: 1.42, fontFace: "Calibri" });

  addSectionLabel(sl, "WHEN TO USE WARFARIN (Not DOACs)", 0.25, 4.0, 4.6);
  sl.addText("• Mechanical prosthetic heart valves\n• Moderate-to-severe Mitral Stenosis (rheumatic)\n• Severe CKD (CrCl <15 mL/min) — most DOACs not studied\n• DOACs not available / unaffordable", {
    x: 0.25, y: 4.3, w: 4.6, h: 0.9,
    fontSize: 9.5, color: C.darkT, fontFace: "Calibri"
  });

  addBox(sl, 0.25, 5.25, 9.5, 0.22, C.teal, C.teal,
    "DOACs are preferred over warfarin in non-valvular AF — ACC/AHA Class I Recommendation", 9.5, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 17 — CATHETER ABLATION
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Catheter Ablation of AF", "Slide 17 / 20");

  // Core concept
  addBox(sl, 0.25, 0.85, 9.5, 0.68, C.navy, C.gold,
    "PULMONARY VEIN ISOLATION (PVI) — The cornerstone of AF ablation. Electrically isolates trigger foci in the PVs from the left atrium using radiofrequency energy or cryotherapy.", 11, true, C.white);

  addSectionLabel(sl, "INDICATIONS FOR ABLATION", 0.25, 1.68, 4.6);
  const indAbl = [
    "Symptomatic paroxysmal AF — failed ≥1 AAD (Class I)",
    "Symptomatic persistent AF — reasonable option",
    "Tachycardia-induced cardiomyopathy from AF",
    "Patient preference for rhythm control without drugs",
    "HFrEF with AF — ablation improves EF (CASTLE-AF trial)",
    "As first-line rhythm control option in selected patients",
  ];
  sl.addText(makeBullets(indAbl, 10.5), { x: 0.25, y: 1.98, w: 4.6, h: 2.2, fontFace: "Calibri" });

  addSectionLabel(sl, "CONTRAINDICATIONS / CAUTION", 5.05, 1.68, 4.7);
  const contIndAbl = [
    "LA thrombus present (require TEE before procedure)",
    "Severe LV dysfunction (relative; may still benefit)",
    "Unable to anticoagulate peri-procedurally",
    "Permanent AF with accepted rate strategy",
    "High surgical risk (comorbidities)",
  ];
  sl.addText(makeBullets(contIndAbl, 10.5, C.red), { x: 5.05, y: 1.98, w: 4.7, h: 1.7, fontFace: "Calibri" });

  addSectionLabel(sl, "SUCCESS RATES", 5.05, 3.72, 4.7);
  addBox(sl, 5.05, 4.05, 2.25, 0.88, C.lightG, "1E8449", "Paroxysmal AF\n~70-80% single procedure\n~90% with redo", 10, false, C.darkT);
  addBox(sl, 7.4, 4.05, 2.35, 0.88, C.lightY, "B7950B", "Persistent AF\n~50-70% single procedure\nLower success rate", 10, false, C.darkT);

  addSectionLabel(sl, "COMPLICATIONS (<3%)", 0.25, 3.72, 4.6);
  const comp = ["Cardiac tamponade / pericardial effusion", "Pulmonary vein stenosis", "Atrioesophageal fistula (rare but fatal)", "Stroke / TIA (peri-procedural)", "Phrenic nerve injury", "Vascular access complications"];
  sl.addText(makeBullets(comp, 9.5, C.red), { x: 0.25, y: 4.05, w: 4.6, h: 1.3, fontFace: "Calibri" });

  addBox(sl, 0.25, 5.2, 9.5, 0.22, C.teal, C.teal,
    "CABANA Trial: Ablation did not reduce primary endpoint (mortality, stroke, etc.) in ITT analysis but showed benefit in per-protocol analysis and quality of life", 9, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 18 — AF IN SPECIAL POPULATIONS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "AF in Special Populations", "Slide 18 / 20");

  const populations = [
    {
      title: "AF in HEART FAILURE",
      content: "• Bidirectional relationship — HF causes AF, AF worsens HF\n• Rate control with beta-blockers or digoxin\n• AVOID verapamil/diltiazem in HFrEF\n• Consider ablation — CASTLE-AF trial: ablation reduced mortality + HF hospitalization\n• Anticoagulate if CHA₂DS₂-VASc ≥1 (male) / ≥2 (female)",
      fill: C.lightB, border: C.teal
    },
    {
      title: "AF in PREGNANCY",
      content: "• Rare but can occur in structural heart disease\n• Rate control: Digoxin or metoprolol (safe in pregnancy)\n• AVOID warfarin in 1st trimester (teratogenic)\n• AVOID DOACs (not studied, may cross placenta)\n• Use LMWH throughout; warfarin in 2nd-3rd trimester for mechanical valves",
      fill: C.lightG, border: "1E8449"
    },
    {
      title: "AF in ELDERLY (>75 yrs)",
      content: "• All have CHA₂DS₂-VASc ≥2 → anticoagulate!\n• Atypical presentation: falls, syncope, cognitive decline\n• DOACs preferred over warfarin\n• Higher bleeding risk — correct modifiable factors\n• Reduced digoxin/drug doses (renal clearance ↓)\n• Symptom control, QoL focus",
      fill: C.lightY, border: "B7950B"
    },
    {
      title: "AF in CKD",
      content: "• DOACs: dose-adjust for renal function\n  - Apixaban: preferred even in CKD stage 3-4\n  - Dabigatran: AVOID if CrCl <30 mL/min\n  - Rivaroxaban: reduce dose if CrCl 15-49\n• Warfarin: acceptable but variable INR in CKD\n• Dialysis patients: anticoagulation controversial",
      fill: C.lightR, border: C.red
    },
  ];

  populations.forEach((p, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    addSectionLabel(sl, p.title, 0.22 + col * 5.0, 0.85 + row * 2.28, 4.7);
    addBox(sl, 0.22 + col * 5.0, 1.18 + row * 2.28, 4.7, 1.8, p.fill, p.border, p.content, 9.5, false, C.darkT);
  });

  addBox(sl, 0.25, 5.2, 9.5, 0.22, C.navy, C.gold,
    "WPW + AF: NEVER use AV nodal blockers — risk of VF! → IV Procainamide / emergent cardioversion → refer for ablation", 9.5, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 19 — STROKE PREVENTION: LAA OCCLUSION & INTEGRATED CARE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.offW } });
  addHeader(sl, "Stroke Prevention & Integrated AF Care", "Slide 19 / 20");

  addSectionLabel(sl, "STROKE PATHOPHYSIOLOGY IN AF", 0.25, 0.85, 5.5);
  addBox(sl, 0.25, 1.18, 5.5, 1.15, C.lightB, C.teal,
    "PRIMARY SOURCE: Left Atrial Appendage (LAA) — stagnant blood flow → thrombus formation → embolism → cardioembolic stroke.\n\nAfter cardioversion: 'ATRIAL STUNNING' — mechanical function impaired for weeks even after electrical sinus rhythm → thrombus can still form!\n\nValvular AF (Mitral Stenosis): higher thrombus risk; always warfarin.", 10, false, C.darkT);

  addSectionLabel(sl, "LAA OCCLUSION — WATCHMAN DEVICE", 0.25, 2.48, 5.5);
  addBox(sl, 0.25, 2.8, 5.5, 1.35, C.lightG, "1E8449",
    "INDICATIONS: High stroke risk + contraindication to long-term anticoagulation\n\n• Transcatheter device implanted in LAA\n• Reduces AF-related stroke comparable to warfarin\n• Short-term anticoagulation required after device placement\n• TEE pre-procedure to confirm no peri-device leak\n• PROTECT-AF & PREVAIL trials support use\n• May allow eventual discontinuation of OAC", 9.5, false, C.darkT);

  addSectionLabel(sl, "SURGICAL AF ABLATION (MAZE PROCEDURE)", 0.25, 4.25, 5.5);
  addBox(sl, 0.25, 4.58, 5.5, 0.65, C.lightY, "B7950B",
    "Creates electrical barriers to prevent AF. Useful in patients undergoing cardiac surgery (concomitant). Surgical LAA closure may reduce stroke risk but thrombus can form in remnant.", 9.5, false, C.darkT);

  addSectionLabel(sl, "INTEGRATED / ABC PATHWAY (ESC/ACC)", 5.95, 0.85, 3.8);
  const abc = [
    ["A — Anticoagulation", "Stroke prevention first\nCHA₂DS₂-VASc guided OAC", C.lightB, C.teal],
    ["B — Better symptom control", "Rate + rhythm control\n+ lifestyle modification", C.lightG, "1E8449"],
    ["C — Cardiovascular risk factor\n& comorbidity management", "HTN, DM, OSA, obesity, HF\n= upstream therapy", C.lightY, "B7950B"],
  ];
  abc.forEach((a, i) => addBox(sl, 5.95, 1.18 + i * 1.2, 3.8, 1.12, a[2], a[3], `${a[0]}\n${a[1]}`, 10, false, C.darkT));

  addBox(sl, 5.95, 4.78, 3.8, 0.52, C.navy, C.gold,
    "Integrated AF care with ABC pathway reduces hospitalizations & mortality (AFFIRM, RACE II, EAST-AFNET 4)", 9, true, C.white);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 20 — SUMMARY & KEY TAKEAWAYS
// ═══════════════════════════════════════════════════════════════════════════════
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  const sl = pres.addSlide();
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navy } });
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 0.72, w: 10, h: 0.06, fill: { color: C.gold } });
  sl.addShape(pres.ShapeType.rect, { x: 0, y: 4.7, w: 10, h: 0.925, fill: { color: C.teal } });

  sl.addText("KEY TAKEAWAYS", {
    x: 0.3, y: 0.06, w: 9.4, h: 0.64, margin: 0,
    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri",
    charSpacing: 3, align: "center"
  });

  const takeaways = [
    ["1", "AF is the most common SUSTAINED arrhythmia. It is a disease continuum (4 stages). Define & stage it properly.", C.lightB, C.teal],
    ["2", "Pathophysiology: Multiple wavelet reentry + PV ectopy. AF begets AF — early rhythm control matters.", C.lightG, "1E8449"],
    ["3", "THREE PILLARS: Symptom control, stroke prevention, risk factor modification. All three must be addressed.", C.lightY, "B7950B"],
    ["4", "CHA₂DS₂-VASc guides anticoagulation. DOACs are preferred over warfarin in non-valvular AF.", C.lightB, C.teal],
    ["5", "Rate control first in most stable patients. Rhythm control for symptomatic, young, or tachycardiomyopathy patients.", C.lightG, "1E8449"],
    ["6", "HAS-BLED identifies correctable bleeding risk — NOT a reason to withhold anticoagulation.", C.lightY, "B7950B"],
    ["7", "ABLATION (PVI) is first-line option in symptomatic paroxysmal AF. CASTLE-AF supports ablation in HFrEF.", C.lightR, C.red],
    ["8", "WPW + AF is a MEDICAL EMERGENCY — never AV nodal blockers — IV Procainamide / cardioversion + ablation.", C.lightR, C.red],
  ];

  takeaways.forEach((t, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    sl.addShape(pres.ShapeType.roundRect, {
      x: 0.22 + col * 5.0, y: 0.88 + row * 0.87, w: 4.72, h: 0.8,
      fill: { color: t[2] }, line: { color: t[3], width: 1.2 }, rectRadius: 0.07
    });
    sl.addShape(pres.ShapeType.ellipse, {
      x: 0.26 + col * 5.0, y: 0.93 + row * 0.87, w: 0.32, h: 0.32,
      fill: { color: t[3] }, line: { color: t[3] }
    });
    sl.addText(t[0], { x: 0.26 + col * 5.0, y: 0.93 + row * 0.87, w: 0.32, h: 0.32, fontSize: 9, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    sl.addText(t[1], { x: 0.62 + col * 5.0, y: 0.88 + row * 0.87, w: 4.28, h: 0.8, fontSize: 9.5, color: C.darkT, fontFace: "Calibri", valign: "middle", wrap: true, margin: 3 });
  });

  sl.addText("\"AF management is not just about drugs — it's about addressing the whole patient: their lifestyle, comorbidities, and stroke risk.\"", {
    x: 0.3, y: 4.73, w: 9.4, h: 0.45,
    fontSize: 11, color: C.white, fontFace: "Calibri", italic: true, align: "center", valign: "middle"
  });

  sl.addText("Harrison's Principles of Internal Medicine 22E (2025)  |  2023 ACC/AHA/ACCP/HRS AF Guidelines", {
    x: 0.3, y: 5.2, w: 9.4, h: 0.25, margin: 0,
    fontSize: 8.5, color: C.gold, fontFace: "Calibri", align: "center", italic: true
  });
}

// ─── Write file ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/af-ppt/Atrial_Fibrillation_Seminar.pptx" })
  .then(() => console.log("SUCCESS: Atrial_Fibrillation_Seminar.pptx created!"))
  .catch(e => console.error("ERROR:", e));

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/af-ppt/create_af_ppt.js'