Marrow cardiology subject-wise PDF topic wise notes download 2025

ACC AHA cardiology guidelines 2025 2026 new updated

ACC AHA guideline 2025

ls -la /tmp/workspace/ 2>/dev/null || mkdir -p /tmp/workspace && echo "workspace ready"

mkdir -p /tmp/workspace/cardiology-guidelines && python3 << 'PYEOF' from reportlab.lib.pagesizes import A4, letter from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import inch, cm from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, HRFlowable, PageBreak, KeepTogether) from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY from reportlab.platypus import BaseDocTemplate, Frame, PageTemplate from reportlab.lib.colors import HexColor import datetime # ── Color Palette ────────────────────────────────────────────────────────────── DARK_BLUE = HexColor("#1A3A5C") MED_BLUE = HexColor("#2E6DA4") LIGHT_BLUE = HexColor("#D6E8F7") ACCENT_RED = HexColor("#C0392B") GOLD = HexColor("#E67E22") LIGHT_GRAY = HexColor("#F4F6F8") MID_GRAY = HexColor("#BDC3C7") DARK_GRAY = HexColor("#2C3E50") WHITE = colors.white GREEN = HexColor("#1E8449") LIGHT_GREEN = HexColor("#D5F5E3") ORANGE_LIGHT= HexColor("#FDEBD0") RED_LIGHT = HexColor("#FADBD8") OUTPUT = "/tmp/workspace/cardiology-guidelines/ACC_AHA_Guidelines_2025_2026_Summary.pdf" doc = SimpleDocTemplate(OUTPUT, pagesize=A4, rightMargin=1.8*cm, leftMargin=1.8*cm, topMargin=2*cm, bottomMargin=2*cm) styles = getSampleStyleSheet() # ── Custom Styles ────────────────────────────────────────────────────────────── def S(name, **kw): return ParagraphStyle(name, **kw) title_style = S("DocTitle", fontSize=22, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER, spaceAfter=6) subtitle_style = S("DocSub", fontSize=13, textColor=LIGHT_BLUE, fontName="Helvetica", alignment=TA_CENTER, spaceAfter=4) date_style = S("DocDate", fontSize=9, textColor=MID_GRAY, fontName="Helvetica", alignment=TA_CENTER, spaceAfter=0) sec_head = S("SecHead", fontSize=13, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_LEFT, spaceBefore=14, spaceAfter=6, leftIndent=6) body = S("Body", fontSize=8.5, textColor=DARK_GRAY, fontName="Helvetica", leading=12, spaceAfter=4, alignment=TA_JUSTIFY) bullet = S("Bullet", fontSize=8.2, textColor=DARK_GRAY, fontName="Helvetica", leading=12, spaceAfter=3, leftIndent=12, bulletIndent=4, alignment=TA_LEFT) col_head = S("ColHead", fontSize=8, textColor=WHITE, fontName="Helvetica-Bold", alignment=TA_CENTER, leading=11) cell_body = S("CellBody", fontSize=7.5, textColor=DARK_GRAY, fontName="Helvetica", leading=10, alignment=TA_LEFT) cell_new = S("CellNew", fontSize=7.5, textColor=HexColor("#145A32"), fontName="Helvetica-Bold", leading=10, alignment=TA_LEFT) note_style= S("Note", fontSize=7, textColor=HexColor("#555555"), fontName="Helvetica-Oblique", leading=10, spaceAfter=3) footer_style = S("Footer", fontSize=7, textColor=MID_GRAY, fontName="Helvetica", alignment=TA_CENTER) pmid_style = S("PMID", fontSize=7, textColor=MED_BLUE, fontName="Helvetica", leading=9) # ── Helper: Section Banner ───────────────────────────────────────────────────── def section_banner(text, color=DARK_BLUE): tbl = Table([[Paragraph(text, sec_head)]], colWidths=[doc.width]) tbl.setStyle(TableStyle([ ("BACKGROUND", (0,0), (-1,-1), color), ("ROUNDEDCORNERS", [4,4,4,4]), ("TOPPADDING", (0,0), (-1,-1), 6), ("BOTTOMPADDING",(0,0), (-1,-1), 6), ("LEFTPADDING", (0,0), (-1,-1), 10), ])) return tbl # ── Helper: Comparison Table ────────────────────────────────────────────────── def comparison_table(headers, rows, col_widths): header_row = [Paragraph(h, col_head) for h in headers] data = [header_row] for row in rows: data.append([Paragraph(str(c), cell_body) for c in row]) tbl = Table(data, colWidths=col_widths, repeatRows=1) style = TableStyle([ ("BACKGROUND", (0,0), (-1,0), MED_BLUE), ("TEXTCOLOR", (0,0), (-1,0), WHITE), ("ALIGN", (0,0), (-1,-1), "LEFT"), ("VALIGN", (0,0), (-1,-1), "TOP"), ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"), ("FONTSIZE", (0,0), (-1,0), 8), ("BOTTOMPADDING",(0,0), (-1,0), 6), ("TOPPADDING", (0,0), (-1,0), 6), ("ROWBACKGROUNDS",(0,1), (-1,-1), [LIGHT_GRAY, WHITE]), ("GRID", (0,0), (-1,-1), 0.4, MID_GRAY), ("TOPPADDING", (0,1), (-1,-1), 4), ("BOTTOMPADDING",(0,1), (-1,-1), 4), ("LEFTPADDING", (0,0), (-1,-1), 5), ("RIGHTPADDING", (0,0), (-1,-1), 5), ]) tbl.setStyle(style) return tbl # ── Helper: Highlight box ───────────────────────────────────────────────────── def highlight_box(text, bg=LIGHT_BLUE, border=MED_BLUE): p = Paragraph(text, S("HBox", fontSize=8, textColor=DARK_GRAY, fontName="Helvetica", leading=11, alignment=TA_LEFT)) t = Table([[p]], colWidths=[doc.width]) t.setStyle(TableStyle([ ("BACKGROUND", (0,0), (-1,-1), bg), ("BOX", (0,0), (-1,-1), 0.8, border), ("TOPPADDING", (0,0), (-1,-1), 6), ("BOTTOMPADDING",(0,0), (-1,-1), 6), ("LEFTPADDING", (0,0), (-1,-1), 10), ])) return t # ══════════════════════════════════════════════════════════════════════════════ # BUILD CONTENT # ══════════════════════════════════════════════════════════════════════════════ story = [] # ── COVER BLOCK ─────────────────────────────────────────────────────────────── cover_title = Table( [[Paragraph("ACC / AHA Cardiology Guidelines", title_style)], [Paragraph("2025–2026 Key Changes vs Prior Versions", subtitle_style)], [Paragraph("Comparative Summary | July 2026", date_style)]], colWidths=[doc.width] ) cover_title.setStyle(TableStyle([ ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE), ("TOPPADDING", (0,0), (-1,-1), 14), ("BOTTOMPADDING",(0,0), (-1,-1), 14), ("LEFTPADDING", (0,0), (-1,-1), 16), ])) story.append(cover_title) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Disclaimer:</b> This document is an educational summary for clinicians and trainees. " "Always refer to the official full-text guidelines for clinical decision-making. " "PMIDs and official links are provided for each guideline." )) story.append(Spacer(1, 0.4*cm)) # ── CONTENTS LIST ───────────────────────────────────────────────────────────── story.append(section_banner("Guidelines Covered in This Summary", MED_BLUE)) story.append(Spacer(1, 0.2*cm)) toc_data = [ ["#", "Guideline", "Year", "Replaces", "PMID"], ["1", "ACS (Acute Coronary Syndromes)", "2025", "2014 NSTEMI + 2013 STEMI (separate)", "40014670"], ["2", "Hypertension", "2025", "2017 ACC/AHA Hypertension", "40815242"], ["3", "Dyslipidemia / Cholesterol", "2026", "2018 Blood Cholesterol Guideline", "—"], ["4", "Acute Pulmonary Embolism", "2026", "2019 PE Guideline", "41712898"], ["5", "Adults with Congenital Heart Disease", "2025/26", "2018 ACHD Guideline", "41411480"], ["6", "Cardiovascular-Kidney-Metabolic Syndrome", "2026", "New framework (no prior unified GL)", "42265997"], ["7", "ICD / CRT / Pacing (AUC)", "2025", "2018 AUC for Devices", "39808105"], ] toc_cw = [0.5*cm, 9.5*cm, 2*cm, 4.5*cm, 2.5*cm] story.append(comparison_table(toc_data[0], toc_data[1:], toc_cw)) story.append(Spacer(1, 0.5*cm)) # ══════════════════════════════════════════════════════════════════════════════ # GUIDELINE 1 — ACS # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("1. 2025 ACC/AHA/ACEP/NAEMSP/SCAI — Acute Coronary Syndromes (ACS)")) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Published:</b> April–June 2025 | <b>Journal:</b> Circulation & JACC | " "<b>PMID:</b> 40014670 | <b>Replaces:</b> 2014 NSTEMI GL + 2013 STEMI GL (two separate documents)", note_style)) story.append(Spacer(1, 0.15*cm)) acs_rows = [ ["Domain", "Prior Guideline (2013–2014)", "NEW 2025 Recommendation"], ["Structure", "Two separate documents:\n2013 STEMI GL\n2014 NSTEMI/UA GL", "UNIFIED single ACS guideline covering STEMI, NSTEMI, UA, and MINOCA together"], ["Troponin / Dx", "Conventional troponin assays; serial at 0, 3–6 h", "High-sensitivity troponin (hs-cTn) preferred; 0/1 h or 0/2 h rapid rule-out algorithms endorsed"], ["Antithrombotic\nStrategy", "Clopidogrel or prasugrel or ticagrelor; no clear hierarchy;\ndual antiplatelet for 12 months default", "Ticagrelor or prasugrel preferred over clopidogrel (Class I);\nde-escalation strategies individualized;\nshort DAPT (1–3 mo) + P2Y12 monotherapy option for high-bleed risk"], ["Radial Access", "Femoral or radial — operator discretion;\nno strong preference", "Radial access preferred over femoral for PCI (Class I) — reduces bleeding and vascular complications"], ["MINOCA", "Not addressed as distinct entity", "New dedicated section: workup algorithm (cardiac MRI, OCT, IVUS, vasospasm testing), tailored Rx"], ["Door-to-Balloon", "≤90 min for STEMI (PCI center)\n≤120 min if transfer required", "Targets unchanged but stronger emphasis on system-of-care metrics and telemedicine ECG transmission"], ["Heart Team /\nRevascularization", "CABG vs PCI decision by Heart Team", "Heart Team model reinforced; SYNTAX score II 2020 for complex CAD risk stratification endorsed"], ["Cardiogenic Shock", "Early revascularization (IIa); IABP routine (IIa)", "Immediate revascularization (Class I); IABP no longer recommended routinely (Class III Harm); consider Impella/ECMO for refractory shock"], ["SGLT-2i / GLP-1 RA", "Not mentioned", "SGLT-2 inhibitors recommended in ACS patients with HF or T2DM (Class I) prior to discharge"], ] acs_cw = [3.2*cm, 7.5*cm, 8.0*cm] story.append(comparison_table(acs_rows[0], acs_rows[1:], acs_cw)) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Take-Home Pearl:</b> The 2025 ACS GL is the first to unify STEMI and NSTEMI into a single document. " "The biggest practice changes are radial-first access (Class I), " "hs-troponin rapid rule-out pathways, de-escalation DAPT strategies, and SGLT-2i at discharge.", bg=LIGHT_GREEN, border=GREEN)) story.append(Spacer(1, 0.5*cm)) # ══════════════════════════════════════════════════════════════════════════════ # GUIDELINE 2 — HYPERTENSION # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("2. 2025 AHA/ACC Guideline — Hypertension in Adults")) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Published:</b> September–November 2025 | <b>Journal:</b> Circulation, Hypertension & JACC | " "<b>PMID:</b> 40815242 | <b>Replaces:</b> 2017 ACC/AHA Hypertension Guideline", note_style)) story.append(Spacer(1, 0.15*cm)) htn_rows = [ ["Domain", "Prior Guideline (2017)", "NEW 2025 Recommendation"], ["BP Classification", "Normal <120/80\nElevated 120–129/<80\nStage 1 HTN 130–139/80–89\nStage 2 HTN ≥140/≥90", "Classification retained but thresholds refined;\nExpanded guidance on out-of-office BP (ABPM/HBPM) for diagnosis confirmation"], ["BP Target", "<130/80 mmHg for most adults;\n<130/80 in high CVD risk", "<130/80 mmHg maintained for high-risk;\nIndividualized targets for elderly (≥75 y), frailty, CKD;\nSBP 120–129 in selected very high-risk patients"], ["First-Line Therapy", "Thiazides, CCBs, ACEi/ARBs as first-line;\nBeta-blockers not first-line unless compelling indication", "Same 4 drug classes; updated race/ethnicity guidance;\nACEi and ARBs interchangeable (no superiority);\nFixed-dose combination therapy earlier in treatment algorithm"], ["Novel Drug Classes", "SGLT-2i, GLP-1 RA not included", "SGLT-2 inhibitors and GLP-1 RAs: BP-lowering benefit acknowledged, considered in patients with CKD, HF, or obesity; not standalone antihypertensives"], ["Resistant HTN", "Add mineralocorticoid antagonist (spironolactone) as 4th agent", "Spironolactone first add-on for resistant HTN; amiloride as alternative; renal denervation: Class IIb for patients failing pharmacotherapy"], ["Pregnancy", "Labetalol, nifedipine, methyldopa", "BP threshold for treatment lowered to ≥140/90 (not just severe HTN); IV labetalol or hydralazine for hypertensive emergency; more aggressive inpatient monitoring"], ["Older Adults", "Target <130/80 if tolerated", "Individualized; consider <130/80 if tolerated and fit; <140/80 acceptable in frail elderly; consider orthostatic hypotension risk"], ["Secondary HTN\nScreening", "Screen if resistant or early-onset HTN", "Expanded screening criteria; aldosterone-to-renin ratio for PA screening in all Stage 2 HTN; sleep apnea screening emphasized"], ] htn_cw = [3.2*cm, 7.2*cm, 8.3*cm] story.append(comparison_table(htn_rows[0], htn_rows[1:], htn_cw)) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Take-Home Pearl:</b> The 2025 HTN GL is the first major update in 8 years. " "BP targets are largely preserved, but SGLT-2i/GLP-1 RAs are recognized, renal denervation gets Class IIb, " "pregnancy thresholds are lowered, and combination therapy is endorsed earlier.", bg=LIGHT_GREEN, border=GREEN)) story.append(PageBreak()) # ══════════════════════════════════════════════════════════════════════════════ # GUIDELINE 3 — DYSLIPIDEMIA # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("3. 2026 ACC/AHA Multisociety Guideline — Dyslipidemia Management")) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Published:</b> March 13, 2026 | <b>Journal:</b> JACC & Circulation | " "<b>Source:</b> acc.org | <b>Replaces:</b> 2018 ACC/AHA Blood Cholesterol Guideline", note_style)) story.append(Spacer(1, 0.15*cm)) lip_rows = [ ["Domain", "Prior Guideline (2018)", "NEW 2026 Recommendation"], ["LDL-C Targets", "Risk-based thresholds:\n• Very high risk: <70 mg/dL\n• High risk: <100 mg/dL\n• Moderate risk: lifestyle", "Stricter, more explicit targets:\n• Very high risk (recurrent ASCVD): LDL-C <55 mg/dL\n• High risk (established ASCVD): <70 mg/dL\n• Primary prevention high-risk: <100 mg/dL\n• Emphasizes absolute LDL reduction"], ["LDL-Years Concept", "Not present", "NEW: Cumulative LDL exposure over lifetime ('LDL-years') is key driver of ASCVD risk;\nearly and sustained LDL lowering emphasized even in younger adults"], ["Risk Assessment", "Pooled Cohort Equation (PCE) primary tool;\nCAC scoring for borderline-risk decision", "PCE retained; limitations acknowledged;\nCAC scoring refined — selective use for intermediate-risk;\nLp(a) and ApoB testing strongly recommended for risk refinement"], ["Lipoprotein(a)", "Measure once in lifetime for risk assessment", "Lp(a) ≥125 nmol/L (≥50 mg/dL) = high-risk modifier;\nanti-Lp(a) agents in pipeline; cascade family screening for elevated Lp(a)"], ["ApoB Testing", "Optional, for metabolic syndrome", "ApoB ≥ 100 mg/dL = elevated risk regardless of LDL-C;\nApoB preferred over LDL-C for patients on statins or with hypertriglyceridemia"], ["Statin Therapy", "Moderate/high-intensity statin by risk category", "Same intensity framework retained but earlier initiation encouraged;\nhigh-intensity statin as default for ASCVD patients"], ["Non-Statin Therapies", "Ezetimibe: Class I add-on for very high risk;\nPCSK9i: Class IIa if LDL not at goal", "Ezetimibe: first add-on after max-dose statin (Class I);\nPCSK9 inhibitors (evolocumab, alirocumab): Class I for very high risk;\nInclisiran (siRNA): Class IIa;\nBempedoic acid: Class IIa for statin-intolerant"], ["Hypertriglyceridemia", "Fibrates for TG >500 mg/dL;\nniacin no longer recommended", "Icosapentaenoic acid (EPA/Vascepa): Class I for TG ≥150 mg/dL + statin;\nFibrates for severe TG (>500);\nOmega-3 combo products not recommended"], ["Special Populations", "Limited guidance on CKD, elderly, women", "Dedicated sections: CKD stages 3–5, elderly (≥75 y), women, HIV, South Asians, childhood FH;\nhighly individualized risk-benefit discussions emphasized"], ] lip_cw = [3.0*cm, 7.3*cm, 8.4*cm] story.append(comparison_table(lip_rows[0], lip_rows[1:], lip_cw)) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Take-Home Pearl:</b> The 2026 Dyslipidemia GL introduces the 'LDL-years' concept, " "sets LDL-C <55 mg/dL for recurrent ASCVD, elevates Lp(a) and ApoB to routine testing, " "and gives inclisiran Class IIa status. EPA (icosapentaenoic acid) gets Class I for hypertriglyceridemia on statins.", bg=LIGHT_GREEN, border=GREEN)) story.append(Spacer(1, 0.5*cm)) # ══════════════════════════════════════════════════════════════════════════════ # GUIDELINE 4 — PULMONARY EMBOLISM # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("4. 2026 AHA/ACC Guideline — Acute Pulmonary Embolism (PE)")) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Published:</b> March–April 2026 | <b>Journal:</b> JACC & Circulation | " "<b>PMID:</b> 41712898 | <b>Replaces:</b> 2019 AHA Scientific Statement on PE", note_style)) story.append(Spacer(1, 0.15*cm)) pe_rows = [ ["Domain", "Prior (2019 AHA Statement)", "NEW 2026 Recommendation"], ["Risk Stratification", "Massive / Submassive / Low-risk\nbased on hemodynamics + RV strain", "Terminology updated: High-risk / Intermediate-high / Intermediate-low / Low-risk;\naligns with ESC 2019/2022 framework"], ["PERT Teams", "Mentioned as emerging approach (IIb)", "Pulmonary Embolism Response Teams (PERT) formally endorsed (Class IIa);\nmultidisciplinary decision-making for intermediate/high-risk PE"], ["Systemic Thrombolysis", "Class I for massive PE with hemodynamic instability;\nClass IIb for submassive with clinical deterioration", "Maintained for high-risk PE;\nrescue thrombolysis pathway clearly defined;\ncontraindication checklist updated"], ["Catheter-Directed\nTherapy (CDT)", "Class IIa for massive/submassive\nPE if thrombolysis contraindicated", "Expanded: CDT (pharmacomechanical) Class IIa for intermediate-high risk;\nultrasound-assisted CDT (EKOS) acknowledged;\ncenter experience required"], ["Anticoagulation", "LMWH or UFH acutely;\nDOACs for long-term;\nNO specific duration guidance for provoked vs unprovoked", "DOACs (rivaroxaban, apixaban) preferred for initial + long-term Rx;\nClear duration guidance: 3–6 months provoked, ≥12 months unprovoked;\nVKA only if DOAC not available/appropriate (e.g. antiphospholipid syndrome)"], ["CTEPH Surveillance", "Limited post-PE follow-up guidance", "Echocardiogram at 3–6 months post-PE;\nV/Q scan if CTEPH suspected;\nreferral to CTEPH center if confirmed;\nnew medical therapies (riociguat) mentioned"], ["Pregnancy", "LMWH throughout; thrombolysis only if life-threatening", "LMWH strongly preferred;\nthrombolysis for hemodynamically unstable (Class IIb);\nsurgical embolectomy as option at CTEPH/cardiac surgery centers"], ] pe_cw = [3.2*cm, 7.0*cm, 8.5*cm] story.append(comparison_table(pe_rows[0], pe_rows[1:], pe_cw)) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Take-Home Pearl:</b> Risk terminology is updated (High/Intermediate-High/Low), " "PERT teams get Class IIa endorsement, DOACs are preferred over VKAs, and CTEPH surveillance " "post-PE is now formally recommended.", bg=LIGHT_GREEN, border=GREEN)) story.append(PageBreak()) # ══════════════════════════════════════════════════════════════════════════════ # GUIDELINE 5 — ADULT CHD # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("5. 2025 ACC/AHA/HRS Guideline — Adults with Congenital Heart Disease (ACHD)")) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Published:</b> February 2026 | <b>Journal:</b> JACC & Circulation | " "<b>PMID:</b> 41411480 | <b>Replaces:</b> 2018 AHA/ACC ACHD Guideline", note_style)) story.append(Spacer(1, 0.15*cm)) chd_rows = [ ["Domain", "Prior (2018)", "NEW 2025/26 Recommendation"], ["ACHD Centers", "Referral to specialized centers recommended;\nno formal tiering", "3-tier ACHD center classification (Level 1/2/3) based on complexity;\nmandatory care at Level 3 for complex lesions (Fontan, Eisenmenger, etc.)"], ["Transition of Care", "Brief mention", "Formal transition program from pediatric to adult care:\nstructured handoff at 18–21 y;\nelectronic health record transfer protocols"], ["Pregnancy in CHD", "CARPREG risk score mentioned", "Updated CARPREG II + ZAHARA scores;\nHigh-risk lesions listed (Fontan, PAH, severe LV dysfunction);\nmultidisciplinary pregnancy heart team mandatory for high-risk"], ["Fontan Circulation", "Limited guidance; anticoagulation controversial", "Dedicated Fontan section: surveillance imaging, liver disease monitoring (Fontan-associated liver disease), anticoagulation with DOAC or warfarin;\nFontan conversion criteria updated"], ["Arrhythmia / EP", "General EP referral guidance", "Expanded: intra-cardiac mapping for complex ACHD;\nconduction system pacing (His bundle / LBB pacing) for bradycardia;\nsubcutaneous ICD for selected patients"], ["Pulmonary Arterial\nHypertension (PAH)", "Treat as per PAH guidelines", "PAH in CHD now has lesion-specific algorithms;\nEndothelin antagonists + PDE5i combination therapy;\nEisenmenger: defer Rx until hemodynamic assessment"], ["Imaging", "Echo as primary;\ncardiac MRI for selected cases", "Cardiac MRI upgraded to Class I for many lesions (ToF, systemic RV, Fontan);\n4D flow MRI emerging recommendation (IIb);\nCT for pre-procedural planning"], ] chd_cw = [3.0*cm, 6.8*cm, 8.9*cm] story.append(comparison_table(chd_rows[0], chd_rows[1:], chd_cw)) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Take-Home Pearl:</b> The 2025 ACHD GL introduces formal ACHD center tiering, " "comprehensive Fontan management (including liver disease), updated pregnancy risk tools (CARPREG II), " "and upgrades cardiac MRI to Class I for many lesions.", bg=LIGHT_GREEN, border=GREEN)) story.append(Spacer(1, 0.5*cm)) # ══════════════════════════════════════════════════════════════════════════════ # GUIDELINE 6 — CKM SYNDROME # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("6. 2026 AHA/ACC/ADA/ASN Guideline — Cardiovascular-Kidney-Metabolic (CKM) Syndrome")) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Published:</b> June 9, 2026 | <b>Journal:</b> JACC | " "<b>PMID:</b> 42265997 | <b>New framework — no prior unified guideline</b>", note_style)) story.append(Spacer(1, 0.15*cm)) ckm_rows = [ ["Feature", "Prior Approach (Separate Guidelines)", "NEW 2026 CKM Guideline"], ["Concept / Scope", "CV risk, CKD, and metabolic disease managed by separate guidelines;\nno unified framework", "First unified framework recognizing CKM syndrome:\ninterconnected pathophysiology of CVD, CKD, T2DM, and obesity"], ["CKM Staging", "No staging system", "4 stages: Stage 0 (no risk factors) → Stage 3 (CVD without CKD/metabolic) → Stage 4 (CVD + CKD + metabolic);\nstage guides treatment intensity"], ["SGLT-2 Inhibitors", "Class I for T2DM+HF or CKD (from HF/CKD GLs);\nnot in a unified CVD prevention GL", "Class I across CKM stages with CKD or HF;\nkidney-protective and CV protective benefits codified together"], ["GLP-1 Receptor\nAgonists", "Class I for T2DM + ASCVD (2018 ADA/AHA)", "Class I for CKM Stage 2–3 with obesity + CVD risk;\nsemaglutide, liraglutide, tirzepatide addressed;\nweight loss ≥15% target for CKM risk reduction"], ["Risk Calculator", "PCE / SCORE2 — traditional 10-year CVD risk", "NEW CKM risk calculator integrating CKD (eGFR, albuminuria), metabolic factors;\nlifetime ASCVD risk estimation for younger patients"], ["BP Target in CKD", "<130/80 general; <130/80 in CKD per KDIGO", "Unified target <130/80 for CKM Stage ≥2;\nalbuminuria as key driver of target selection;\nRAS blockade (ACEi/ARB) Class I for proteinuric CKD"], ["Lipid Management", "Managed by Cholesterol GL", "Statin + ezetimibe for CKM Stages 3–4;\nLDL <70 mg/dL for Stage 3+;\nrenal safety considerations for statin selection"], ["Obesity / Weight", "Lifestyle counseling; bariatric surgery for BMI>40", "Obesity: treated as disease modifying CKM risk;\nGLP-1/GIP agonists (tirzepatide) Class I;\nbariatric surgery Class IIa for BMI >35 in CKM Stage 2+"], ] ckm_cw = [3.0*cm, 6.8*cm, 8.9*cm] story.append(comparison_table(ckm_rows[0], ckm_rows[1:], ckm_cw)) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Take-Home Pearl:</b> The 2026 CKM GL is entirely new — no prior unified equivalent. " "It formally stages patients by combined CVD/CKD/metabolic burden and provides a unified treatment algorithm " "placing SGLT-2 inhibitors and GLP-1/GIP agonists as cornerstones of CKM management.", bg=LIGHT_GREEN, border=GREEN)) story.append(PageBreak()) # ══════════════════════════════════════════════════════════════════════════════ # GUIDELINE 7 — DEVICES AUC # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("7. 2025 ACC/AHA Appropriate Use Criteria — ICD, CRT & Pacing")) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( "<b>Published:</b> March 2025 | <b>Journal:</b> JACC | " "<b>PMID:</b> 39808105 | <b>Replaces:</b> 2018 AUC for Device-Based Therapy", note_style)) story.append(Spacer(1, 0.15*cm)) dev_rows = [ ["Domain", "Prior AUC (2018)", "NEW 2025 AUC"], ["Conduction System\nPacing (CSP)", "Not included (technique not established)", "His bundle pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP) included;\nCSP as alternative to RV pacing for patients needing >40% pacing;\nClass IIa for CRT-eligible patients who can't receive BV pacing"], ["Subcutaneous ICD\n(S-ICD)", "Mentioned as alternative in selected patients;\nlimited specific criteria", "S-ICD: Class I when transvenous access is difficult or undesirable;\nexcluded if pacing-dependent or needing ATP;\nscreening algorithm (SENSE screening) emphasized"], ["Wearable Defibrillator\n(WCD)", "IIb for newly diagnosed cardiomyopathy;\npost-MI EF ≤35%", "Bridging role reinforced: newly diagnosed DCM/ischemic CMP with EF ≤35%;\npost-revascularization or post-myocarditis waiting period (3 months);\nnot a permanent ICD substitute"], ["CRT Indications", "EF ≤35%, LBBB, QRS ≥150 ms: Class I;\nQRS 120–149 ms: IIa;\nnon-LBBB: IIb", "LBBB + QRS ≥150 + EF ≤35%: Class I maintained;\nCSP (LBBAP) as alternative to CRT for select patients;\nupdated evidence for non-LBBB morphology (still IIb)"], ["Primary Prevention\nICD — New CM", "Wait 3–6 months GDMT before ICD;\nEF ≤35%", "90-day GDMT optimization mandatory before ICD in newly diagnosed non-ischemic CMP;\nWCD encouraged as bridge;\nre-evaluate EF before implant"], ["Remote Monitoring", "Recommended but not detailed", "Remote device monitoring Class I recommendation;\nspecific alert parameters defined;\nalert response within 24–48 h standard of care"], ["Leadless Pacemakers", "Not included", "Leadless pacemakers (Micra) AUC included:\nappropriate for VVIR pacing indications, elderly, high infection risk;\nnot appropriate if AV synchrony required"], ] dev_cw = [3.2*cm, 6.8*cm, 8.7*cm] story.append(comparison_table(dev_rows[0], dev_rows[1:], dev_cw)) story.append(Spacer(1, 0.3*cm)) story.append(highlight_box( "<b>Take-Home Pearl:</b> The biggest addition in 2025 Devices AUC is conduction system pacing " "(His bundle + LBBAP) as a formal option for CRT-eligible patients and pacing-induced CMP, " "and the inclusion of leadless pacemakers and updated S-ICD criteria.", bg=LIGHT_GREEN, border=GREEN)) story.append(Spacer(1, 0.5*cm)) # ══════════════════════════════════════════════════════════════════════════════ # SUMMARY TABLE — ALL GUIDELINES AT A GLANCE # ══════════════════════════════════════════════════════════════════════════════ story.append(section_banner("Master Comparison: All 2025–2026 Guidelines at a Glance", MED_BLUE)) story.append(Spacer(1, 0.2*cm)) master_rows = [ ["Guideline", "Biggest Change", "Drug/Therapy Highlight", "Key Number to Remember"], ["ACS 2025", "STEMI+NSTEMI unified;\nMINOCA section added", "SGLT-2i at discharge (Class I);\nticagrelor/prasugrel preferred", "Radial access preferred (Class I);\nhs-cTn 0/1 h rule-out"], ["Hypertension 2025", "First update in 8 years;\nSGLT-2i/GLP-1 recognized", "Fixed-dose combos earlier;\nrenal denervation IIb", "Target: <130/80 mmHg for most;\n<140/80 acceptable in frail elderly"], ["Dyslipidemia 2026", "LDL-years concept;\nLp(a) + ApoB routine testing", "Inclisiran Class IIa;\nEPA/Vascepa Class I for TG+statin", "LDL-C <55 mg/dL (recurrent ASCVD);\n<70 mg/dL (established ASCVD)"], ["Pulmonary Embolism 2026", "Risk terminology updated;\nPERT endorsed Class IIa", "DOACs preferred;\nCDT for intermediate-high risk (IIa)", "CTEPH echo at 3–6 months post-PE;\n3–6 mo anticoag for provoked PE"], ["Adult CHD 2025", "3-tier ACHD center classification;\nFontan liver disease section", "DOAC/warfarin for Fontan;\nCSP for ACHD bradycardia", "Cardiac MRI Class I for ToF, Fontan, systemic RV;\nCARPREG II for pregnancy risk"], ["CKM Syndrome 2026", "Entirely new unified framework;\n4-stage CKM classification", "SGLT-2i + GLP-1/GIP agonists Class I;\ntirzepatide for CKM+obesity", "Target LDL <70 mg/dL for Stage 3+;\nBP <130/80 for CKM Stage ≥2"], ["Devices AUC 2025", "Conduction system pacing added;\nleadless pacemakers included", "LBBAP/HBP as CRT alternative;\nS-ICD criteria clarified", "90-day GDMT before ICD in new CM;\nWCD as bridge to ICD"], ] master_cw = [3.0*cm, 5.3*cm, 5.0*cm, 5.4*cm] story.append(comparison_table(master_rows[0], master_rows[1:], master_cw)) story.append(Spacer(1, 0.5*cm)) # ── REFERENCES ──────────────────────────────────────────────────────────────── story.append(section_banner("References & Official Links", DARK_GRAY)) story.append(Spacer(1, 0.2*cm)) refs = [ ("1.", "2025 ACC/AHA ACS Guideline", "Rao SV et al. Circulation. 2025 Apr; JACC 2025 Jun. PMID: 40014670"), ("2.", "2025 AHA/ACC Hypertension Guideline", "Jones DW et al. Circulation 2025 Sep; JACC 2025 Nov. PMID: 40815242"), ("3.", "2026 ACC/AHA Dyslipidemia Guideline", "ACC/AHA. JACC & Circulation. March 13, 2026. acc.org/guidelines"), ("4.", "2026 AHA/ACC Acute PE Guideline", "Creager MA et al. JACC 2026 Apr; Circulation 2026 Mar. PMID: 41712898"), ("5.", "2025 ACC/AHA Adult CHD Guideline", "Gurvitz M et al. JACC & Circulation. Feb 2026. PMID: 41411480"), ("6.", "2026 AHA/ACC/ADA/ASN CKM Guideline", "Ndumele CE et al. JACC. June 9, 2026. PMID: 42265997"), ("7.", "2025 ACC/AHA Devices AUC", "Russo AM et al. JACC. March 2025. PMID: 39808105"), ] for num, title, citation in refs: story.append(Paragraph( f"<b>{num}</b> <b>{title}:</b> {citation}", S("Ref", fontSize=7.5, textColor=DARK_GRAY, fontName="Helvetica", leading=11, spaceAfter=4, leftIndent=8))) story.append(Spacer(1, 0.3*cm)) story.append(HRFlowable(width="100%", thickness=0.5, color=MID_GRAY)) story.append(Spacer(1, 0.2*cm)) story.append(Paragraph( f"Generated by Orris AI | {datetime.date.today().strftime('%B %d, %Y')} | " "Educational use only. Not a substitute for full guideline text. " "Official guidelines available at acc.org and ahajournals.org", footer_style)) # ── BUILD ────────────────────────────────────────────────────────────────────── doc.build(story) print(f"PDF created: {OUTPUT}") PYEOF

ls -lh /tmp/workspace/cardiology-guidelines/