1000497858.jpg
23 years old female with chest pain and epigastric pain and heaviness
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chest pain young women diagnosis management
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Here is a full, structured clinical interpretation for this patient:
ECG Interpretation - 23F with Chest Pain + Epigastric Pain + Heaviness
ECG Findings (12-lead, 25mm/s, 10mm/mV)
| Parameter | Finding |
|---|---|
| Rate | ~75-80 bpm |
| Rhythm | Normal sinus rhythm |
| Axis | Normal (~+60-70°) |
| P waves | Normal, upright in I, II, aVF |
| PR interval | Normal (~140-160 ms) |
| QRS duration | Narrow (<100 ms), no BBB |
| Pathological Q waves | None |
| R-wave progression | Normal (transition at V3-V4) |
| ST segments | Isoelectric - no elevation or depression |
| T waves | Upright V2-V6; prominent/peaked in V3-V5 (normal variant pattern, asymmetric - not hyperacute) |
| QTc | Normal |
Overall: Normal ECG. No signs of STEMI, NSTEMI pattern, or prior infarction. The prominent T waves in the mid-precordial leads (V3-V5) are consistent with a benign early repolarization pattern, which is common in young individuals.
Clinical Assessment
This ECG does NOT show:
- ST elevation (no STEMI)
- ST depression (no subendocardial ischemia)
- Diffuse concave ("saddle-shaped") ST elevation of pericarditis
- Hyperacute T waves of early MI
- PR depression (pericarditis)
- Delta waves (WPW)
- QT prolongation
Differential Diagnosis - 23F, Chest + Epigastric Pain + Heaviness
Given her age, sex, symptom triad, and normal ECG, the most likely causes are non-cardiac, though cardiac causes must be excluded:
Gastrointestinal (Most Likely Given Symptom Pattern)
- GERD / Gastroesophageal Reflux - epigastric burning + retrosternal heaviness is classic; worsened by meals, lying flat
- Peptic Ulcer Disease (PUD) - epigastric pain + chest radiation, especially if NSAID use
- Functional dyspepsia - epigastric heaviness/pressure in young women
- Esophageal spasm - can mimic chest pain and radiate to the epigastrium
- Gastritis / Helicobacter pylori - common in young adults
Cardiac (Must Exclude)
- Pericarditis / Myocarditis - chest pain in young patients after viral illness; ECG may show diffuse ST changes (absent here), but early/focal forms can have normal ECG
- Myocarditis - especially post-viral; troponin elevation would be key
- Prinzmetal (vasospastic) angina - can occur in young women, ECG often normal between episodes
- Hypertrophic cardiomyopathy (HOCM) - usually shows LVH, deep Q waves (not seen here)
Pulmonary
- Pleuritis / Pleurisy - sharp, positional chest pain
- Pulmonary embolism - must consider in young women (especially if on OCPs); sinus tachycardia is the most common ECG finding (not present here)
Musculoskeletal
- Costochondritis - reproducible tenderness on palpation
- Tietze syndrome
Other
- Anxiety / panic disorder - common in young women, "chest tightness/heaviness"
- Anemia - heaviness and exertional symptoms
Recommended Workup
| Test | Rationale |
|---|---|
| Serum troponin I/T (serial x2, 3h apart) | Rule out ACS/myocarditis - single normal ECG is insufficient |
| CK-MB | Additional cardiac marker |
| CBC | Anemia, infection |
| CRP / ESR | Pericarditis/myocarditis inflammation markers |
| Urea / H. pylori test | If PUD/gastritis suspected |
| Upper GI endoscopy | If GI cause suspected and no cardiac resolution |
| Echo | If myocarditis/pericarditis or structural disease considered |
| D-dimer / CTPA | If PE is suspected (OCP use, immobility, risk factors) |
| Urine pregnancy test | Mandatory in reproductive-age females before further workup |
Key Clinical Points
-
A normal ECG does not rule out ACS - serial troponins are mandatory in a patient presenting with chest pain, regardless of ECG findings. This is especially true because young women often have atypical presentations of ACS.
-
The combination of chest pain + epigastric pain + heaviness in a 23-year-old female strongly points toward a GI etiology (GERD, gastritis, PUD) as the most common cause, particularly if symptoms are meal-related or positional.
-
Pericarditis/myocarditis must be considered in young patients - look for a recent viral illness (URI, flu), fever, positional pleuritic component, and pericardial friction rub on auscultation.
-
Oral contraceptive use should be asked about - significantly raises PE risk in young women.
-
The prominent T waves in V3-V5 are a normal finding in young patients and should NOT be over-interpreted as ischemic.
Clinical bottom line: This is a normal ECG in a young woman with a symptom profile most consistent with a GI cause, but ACS and myocarditis/pericarditis must be actively excluded with serial troponins, inflammatory markers, and clinical assessment before attributing the pain to a benign etiology.
Sources: Frameworks for Internal Medicine (chest pain differential, GI causes); Fuster and Hurst's The Heart 15E (acute pericarditis); Tintinalli's Emergency Medicine (ST evaluation, early repolarization); ROSEN's Emergency Medicine (ECG in chest pain)
Can give ketorolac injection
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Ketorolac Injection - Decision Guide for This Patient
Short Answer: Use with Caution / Consider Alternatives First
Drug Profile - Ketorolac (Tromethamine)
| Parameter | Details |
|---|---|
| Class | Potent NSAID - non-selective COX-1/COX-2 inhibitor |
| Route | IM / IV / oral / intranasal |
| Standard adult dose | 30 mg IM or 15-30 mg IV |
| Onset | Rapid (30 min IM, faster IV) |
| Duration | 6-8 hours |
| Max duration of use | ≤5 days total (systemic) |
| Analgesic potency | Comparable to morphine |
(Goodman & Gilman's Pharmacological Basis of Therapeutics)
Why It Is Problematic in THIS Patient
This 23-year-old has epigastric pain + chest heaviness - a classic GI symptom pattern. Ketorolac's most significant side effects are:
- GI pain (13%), dyspepsia (12%), nausea (12%) - directly overlapping with her presenting symptoms
- Serious adverse GI reactions including ulceration and bleeding via COX-1 inhibition (prostaglandin depletion in gastric mucosa)
- If the underlying cause is gastritis, GERD, or PUD, ketorolac will worsen the condition
Additionally, per ROSEN's Emergency Medicine:
"For acute pain management, ketorolac is rarely indicated in the patient able to receive oral medications, given that 60 mg IM ketorolac is not clinically superior to 800 mg oral ibuprofen."
Specific Contraindications / Risk Factors to Check
Per ROSEN's Box 6.6 - High-risk patients for NSAID adverse events:
| Risk Factor | Status in This Patient |
|---|---|
| GI symptoms (epigastric pain) | PRESENT - HIGH RISK |
| History of peptic ulcer / gastritis | Ask before giving |
| H. pylori infection | Unknown |
| Tobacco / alcohol use | Ask |
| Pregnancy (3rd trimester) | Rule out - urine pregnancy test mandatory |
| Renal impairment | Check if any signs of dehydration |
| Aspirin hypersensitivity / asthma | Ask |
| Dehydration / hypovolemia | Assess clinically |
Key Clinical Concern - Cardiac Not Yet Excluded
If this patient has myocarditis or pericarditis (on the differential from the previous assessment):
- NSAIDs like ibuprofen and aspirin are actually the first-line treatment for pericarditis
- However, myocarditis is a contraindication to NSAIDs (can worsen inflammation and promote arrhythmia)
- Until troponin results are back, avoid if myocarditis is suspected
Recommendation
| Scenario | Action |
|---|---|
| GI cause (GERD/gastritis) suspected | Avoid ketorolac - give PPI (pantoprazole/omeprazole) + antacid instead |
| Troponins pending / cardiac not excluded | Hold ketorolac - musculoskeletal or non-GI pain: consider paracetamol (acetaminophen) 500-1000 mg IV/oral first |
| Pericarditis confirmed | Use ibuprofen 400-600 mg TDS + colchicine (not ketorolac specifically) |
| Myocarditis suspected | Avoid all NSAIDs |
| Musculoskeletal / pleuritic pain, GI cause excluded | Ketorolac 15-30 mg IV or 30 mg IM is reasonable, single dose |
Safer Immediate Alternatives for This Patient
- Paracetamol (Acetaminophen) 1g IV or oral - safest first-line, no GI risk, no cardiac concern
- Antacid + PPI (pantoprazole 40 mg IV/oral) - if GI cause is suspected
- Avoid ketorolac unless GI pathology is confidently excluded
Bottom line: Do NOT give ketorolac as a reflex analgesic in this patient until you know the troponins and have assessed whether the epigastric pain is from GI pathology. Paracetamol is the safer bridge analgesic while workup proceeds.
Sources: Goodman & Gilman's Pharmacological Basis of Therapeutics; ROSEN's Emergency Medicine; Goodman & Gilman
Tell me management of STEMI
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"ST-elevation myocardial infarction" AND "management guidelines"
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"STEMI" AND "reperfusion" AND "guideline"
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Here is a comprehensive, textbook-based STEMI management guide:
Management of STEMI
Core principle: Mortality is directly proportional to total ischemia time. Every minute of delay = more myocardium lost. "Time is muscle."
STEP 1 - Immediate Recognition & Stabilization (First 10 Minutes)
| Action | Detail |
|---|---|
| 12-lead ECG | Within 10 minutes of arrival - mandatory |
| IV access | Two large-bore IVs |
| O2 | Only if SpO2 <90% (avoid hyperoxia) |
| Continuous telemetry | Monitor for arrhythmias (VF causes 50% of STEMI deaths) |
| Portable CXR | Rule out pulmonary edema, aortic dissection |
| Labs | Troponin, CBC, coagulation (aPTT/PT/INR), BMP, Mg, lipid profile, type & screen |
| Urine pregnancy test | All women of reproductive age |
Do NOT wait for troponin results to initiate reperfusion - ECG + clinical picture is sufficient.
STEP 2 - Upstream Medical Therapy (Give Immediately)
Antiplatelets (Dual Antiplatelet Therapy - DAPT)
| Drug | Loading Dose | Maintenance |
|---|---|---|
| Aspirin | 162-325 mg chewed/crushed | 81 mg/day indefinitely |
| Ticagrelor (preferred with PCI) | 180 mg | 90 mg twice daily |
| Prasugrel (preferred with PCI) | 60 mg | 10 mg/day (avoid if >75y, <60kg, hx stroke/TIA) |
| Clopidogrel (if fibrinolysis) | 300-600 mg | 75 mg/day |
Anticoagulation
| Drug | Dose | When |
|---|---|---|
| UFH (preferred for PCI) | 60 units/kg IV bolus (max 4000 U), then 12 units/kg/h | PCI or fibrinolysis |
| Enoxaparin (LMWH) | 30 mg IV bolus → 1 mg/kg SC q12h | Fibrinolysis (preferred) |
| Bivalirudin | 0.75 mg/kg bolus → 1.75 mg/kg/h | PCI (choice in HIT) |
| Fondaparinux | 2.5 mg IV → 2.5 mg SC daily | Fibrinolysis (if no PCI) |
Anti-ischemic Therapy
| Drug | Dose | Notes |
|---|---|---|
| Nitroglycerin | SL or IV infusion | Avoid if SBP <90, HR >100 or <50, RV infarct, PDE5 inhibitor use in 48h |
| Morphine | 2-4 mg IV | Refractory pain only - may mask symptoms |
| Beta-blocker (metoprolol) | 12.5-25 mg oral q6h | Start within 24h; avoid if HF, shock, bradycardia, or hypotension |
STEP 3 - Reperfusion Strategy (The Most Critical Decision)
Option A - Primary PCI (Gold Standard)
- Preferred when door-to-balloon time is ≤90 minutes from first medical contact
- Superior to fibrinolysis: better vessel patency, less reinfarction, less intracranial hemorrhage, improved survival
- Always preferred over fibrinolysis in:
- Cardiogenic shock
- Severe heart failure / pulmonary edema
- Contraindications to fibrinolysis
- Symptom onset >3 hours ago (large clot burden, fibrinolysis less effective)
- Uncertain diagnosis
Option B - Fibrinolytic Therapy
- Use when PCI is not available within 90-120 minutes and symptoms <12 hours
- Target: door-to-needle ≤30 minutes
| Agent | Dose | Notes |
|---|---|---|
| Tenecteplase (TNK-tPA) | 0.5 mg/kg IV single bolus (30-50 mg) | Agent of choice - single bolus, lower bleeding |
| Alteplase (rt-PA) | 15 mg bolus → 0.75 mg/kg/30 min → 0.5 mg/kg/60 min | Fibrin-selective |
| Reteplase (r-PA) | Two 10-unit boluses 30 min apart | |
| Streptokinase | 1.5 million units IV over 60 min | Non-selective; cheapest; allergic reactions possible |
Absolute Contraindications to Fibrinolysis:
- Prior intracranial hemorrhage / hemorrhagic stroke
- Ischemic stroke within 3 months
- Known cerebrovascular AVM / aneurysm / tumor
- Closed head injury within 3 months
- Active aortic dissection
- Active bleeding or bleeding diathesis
- Acute pericarditis
- SBP >180 / DBP >110 mm Hg (severe uncontrolled HTN)
Signs of Successful Reperfusion:
- Relief of chest pain
- >50% reduction in ST elevation at 90 minutes
- Reperfusion arrhythmia (accelerated idioventricular rhythm)
Rescue PCI: if fibrinolysis fails (persistent pain, <50% ST resolution at 90 min)
STEP 4 - Post-Reperfusion / CCU Care
- CCU admission with continuous telemetry for ≥24 hours
- Daily ECG, assessment for recurrent ischemia, new murmurs, HF signs
- Echocardiogram (baseline EF, wall motion abnormalities, thrombus)
- Pacing may be needed: AV block in anterior MI is unstable and usually requires permanent pacemaker
STEP 5 - Long-Term Post-STEMI Medical Therapy (the "ABCDE" drugs)
| Drug Class | Drug & Dose | Duration/Goal |
|---|---|---|
| Aspirin | 81 mg/day | Indefinitely |
| P2Y12 inhibitor | Ticagrelor 90 mg BD or Clopidogrel 75 mg | Minimum 12 months (regardless of stent type) |
| Beta-blocker | Metoprolol succinate (titrate) | Indefinitely; start within 24h |
| ACE inhibitor | Captopril 6.25 mg → titrate up | Within 24h; all patients, especially EF <40%, anterior MI, DM, HTN |
| ARB | Losartan/Valsartan | If ACE-I intolerant |
| Statin (high-intensity) | Atorvastatin 40-80 mg or Rosuvastatin 20-40 mg | Indefinitely; target LDL <70 mg/dL or ≥50% reduction |
| Aldosterone antagonist | Eplerenone/Spironolactone | EF <40% + HF or DM |
| Anticoagulation (if needed) | Warfarin or NOAC | If LV thrombus, AF, or DVT/PE |
ECG-Based Territory Localization
| ST Elevation In | Territory | Culprit Artery |
|---|---|---|
| V1-V6 / LBBB | Anterior + Septal | Proximal LAD or Left Main |
| V2-V4 | Anterior wall | LAD |
| V5-V6 | Lateral wall | LCX |
| II, III, aVF | Inferior wall | RCA or LCX |
| I, aVL | High lateral | Diagonal or proximal LCX |
| V1-V2 depression → get V7-V9 | Posterior | RCA or LCX |
For inferior STEMI: always get right-sided leads (V3R/V4R) to rule out RV infarction - critical because management differs (avoid nitrates, needs IV fluids).
Key Time Targets (AHA/ACC)
| Target | Time |
|---|---|
| ECG from arrival | ≤10 minutes |
| Door-to-balloon (PCI) | ≤90 minutes |
| First medical contact to PCI (transfer) | ≤120 minutes |
| Door-to-needle (fibrinolysis) | ≤30 minutes |
| Symptom onset to fibrinolysis benefit | <12 hours |
Sources: The Washington Manual of Medical Therapeutics; Goldman-Cecil Medicine (Welt & Fang); Fuster and Hurst's The Heart 15E
Create a STEMI management algorithm PDF for ED reference
Reading File
Running Command
ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace not found"
Running Command
mkdir -p /home/daytona/workspace/stemi-pdf && python3 -c "import reportlab; prin…
Writing File
~/stemi-pdf/create_stemi_pdf.py
from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.platypus import (
SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
HRFlowable, KeepTogether
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_RIGHT
from reportlab.platypus.flowables import Flowable
import os
OUTPUT = "/home/daytona/workspace/stemi-pdf/STEMI_ED_Algorithm.pdf"
# ── Colour palette ──────────────────────────────────────────────────────────
RED = colors.HexColor("#C0392B")
DARK_RED = colors.HexColor("#922B21")
ORANGE = colors.HexColor("#E67E22")
YELLOW_BG = colors.HexColor("#FEF9E7")
GREEN = colors.HexColor("#1E8449")
GREEN_BG = colors.HexColor("#EAFAF1")
BLUE = colors.HexColor("#1A5276")
BLUE_LIGHT = colors.HexColor("#D6EAF8")
BLUE_BG = colors.HexColor("#EBF5FB")
GREY_BG = colors.HexColor("#F2F3F4")
GREY_DARK = colors.HexColor("#566573")
WHITE = colors.white
BLACK = colors.HexColor("#1C2833")
# ── Document setup ───────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
OUTPUT,
pagesize=A4,
leftMargin=14*mm, rightMargin=14*mm,
topMargin=14*mm, bottomMargin=14*mm,
title="STEMI ED Management Algorithm",
author="Orris Clinical Reference",
)
W, H = A4
CW = W - 28*mm # content width
styles = getSampleStyleSheet()
def S(name, **kw):
"""Quick style factory."""
base = styles["Normal"]
return ParagraphStyle(name, parent=base, **kw)
# ── Reusable styles ──────────────────────────────────────────────────────────
h_banner = S("h_banner", fontSize=18, textColor=WHITE, alignment=TA_CENTER,
fontName="Helvetica-Bold", leading=22)
h_sub = S("h_sub", fontSize=10, textColor=WHITE, alignment=TA_CENTER,
fontName="Helvetica", leading=13)
step_hdr = S("step_hdr", fontSize=9.5, textColor=WHITE, fontName="Helvetica-Bold",
alignment=TA_CENTER, leading=12)
body = S("body", fontSize=8.2, textColor=BLACK, leading=11)
body_bold = S("body_bold", fontSize=8.2, textColor=BLACK, fontName="Helvetica-Bold", leading=11)
cell_hdr = S("cell_hdr", fontSize=8, textColor=WHITE, fontName="Helvetica-Bold",
alignment=TA_CENTER, leading=10)
cell_body = S("cell_body", fontSize=7.8, textColor=BLACK, leading=10)
cell_bold = S("cell_bold", fontSize=7.8, textColor=BLACK, fontName="Helvetica-Bold", leading=10)
small = S("small", fontSize=7, textColor=GREY_DARK, leading=9)
warn_text = S("warn_text", fontSize=8, textColor=DARK_RED, fontName="Helvetica-Bold", leading=10)
green_txt = S("green_txt", fontSize=8, textColor=GREEN, fontName="Helvetica-Bold", leading=10)
footer_s = S("footer_s", fontSize=6.5, textColor=GREY_DARK, alignment=TA_CENTER, leading=9)
# ── Helper: section header box ───────────────────────────────────────────────
def section_box(title, subtitle=None, bg=BLUE):
rows = [[Paragraph(title, step_hdr)]]
if subtitle:
rows.append([Paragraph(subtitle, h_sub)])
t = Table(rows, colWidths=[CW])
t.setStyle(TableStyle([
("BACKGROUND", (0,0), (-1,-1), bg),
("TOPPADDING", (0,0), (-1,-1), 4),
("BOTTOMPADDING",(0,0),(-1,-1), 4),
("LEFTPADDING", (0,0), (-1,-1), 6),
("RIGHTPADDING",(0,0), (-1,-1), 6),
("ROUNDEDCORNERS", [3]),
]))
return t
# ── Helper: alert box ────────────────────────────────────────────────────────
def alert_box(text, bg=YELLOW_BG, tc=DARK_RED):
st = S("_al", fontSize=8, textColor=tc, fontName="Helvetica-Bold",
leading=10, alignment=TA_CENTER)
t = Table([[Paragraph(text, st)]], colWidths=[CW])
t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,-1), bg),
("BOX", (0,0),(-1,-1), 1.2, tc),
("TOPPADDING", (0,0),(-1,-1), 5),
("BOTTOMPADDING",(0,0),(-1,-1), 5),
("LEFTPADDING", (0,0),(-1,-1), 8),
("RIGHTPADDING",(0,0),(-1,-1), 8),
]))
return t
# ── Helper: two-col table ────────────────────────────────────────────────────
def two_col(headers, rows_data, col_w=None, hdr_bg=BLUE):
if col_w is None:
col_w = [CW*0.38, CW*0.62]
data = [[Paragraph(h, cell_hdr) for h in headers]]
for r in rows_data:
data.append([Paragraph(str(c), cell_body) for c in r])
t = Table(data, colWidths=col_w)
style = [
("BACKGROUND", (0,0), (-1,0), hdr_bg),
("BACKGROUND", (0,1), (-1,-1), GREY_BG),
("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, GREY_BG]),
("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0), (-1,-1), 3),
("BOTTOMPADDING",(0,0), (-1,-1), 3),
("LEFTPADDING", (0,0), (-1,-1), 5),
("RIGHTPADDING", (0,0), (-1,-1), 5),
("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]
t.setStyle(TableStyle(style))
return t
# ── Helper: three-col table ──────────────────────────────────────────────────
def three_col(headers, rows_data, col_w=None, hdr_bg=BLUE):
if col_w is None:
col_w = [CW*0.30, CW*0.36, CW*0.34]
data = [[Paragraph(h, cell_hdr) for h in headers]]
for r in rows_data:
data.append([Paragraph(str(c), cell_body) for c in r])
t = Table(data, colWidths=col_w)
t.setStyle(TableStyle([
("BACKGROUND", (0,0), (-1,0), hdr_bg),
("ROWBACKGROUNDS",(0,1),(-1,-1), [WHITE, GREY_BG]),
("GRID", (0,0), (-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0), (-1,-1), 3),
("BOTTOMPADDING", (0,0), (-1,-1), 3),
("LEFTPADDING", (0,0), (-1,-1), 5),
("RIGHTPADDING", (0,0), (-1,-1), 5),
("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
return t
# ── Helper: bullet list ──────────────────────────────────────────────────────
def bullet_table(items, bg=BLUE_BG, tc=BLACK):
rows = []
for item in items:
rows.append([
Paragraph("•", S("_b", fontSize=8, textColor=RED, fontName="Helvetica-Bold", leading=10)),
Paragraph(item, S("_bi", fontSize=7.8, textColor=tc, leading=10))
])
t = Table(rows, colWidths=[6*mm, CW - 6*mm])
t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,-1), bg),
("TOPPADDING", (0,0),(-1,-1), 2),
("BOTTOMPADDING",(0,0),(-1,-1), 2),
("LEFTPADDING", (0,0),(-1,-1), 3),
("RIGHTPADDING", (0,0),(-1,-1), 3),
("VALIGN", (0,0),(-1,-1), "TOP"),
]))
return t
sp = lambda n=4: Spacer(1, n*mm)
# ════════════════════════════════════════════════════════════════════════════
# BUILD STORY
# ════════════════════════════════════════════════════════════════════════════
story = []
# ── BANNER ───────────────────────────────────────────────────────────────────
banner_data = [
[Paragraph("🫀 STEMI MANAGEMENT ALGORITHM", h_banner)],
[Paragraph("Emergency Department Quick Reference • AHA/ACC Guidelines", h_sub)],
]
banner = Table(banner_data, colWidths=[CW])
banner.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,-1), DARK_RED),
("TOPPADDING", (0,0),(-1,-1), 8),
("BOTTOMPADDING",(0,0),(-1,-1), 8),
("LEFTPADDING", (0,0),(-1,-1), 10),
("RIGHTPADDING", (0,0),(-1,-1), 10),
("ROUNDEDCORNERS", [5]),
]))
story.append(banner)
story.append(sp(3))
# ── KEY PRINCIPLE ────────────────────────────────────────────────────────────
story.append(alert_box(
"⏱ TIME IS MUSCLE — Mortality is directly proportional to total ischemia time. "
"Every 30-minute delay in reperfusion = ~7.5% increase in 1-year mortality.",
bg=colors.HexColor("#FDEDEC"), tc=DARK_RED
))
story.append(sp(3))
# ════════════════ STEP 1 ════════════════════════════════════════════════════
story.append(section_box("STEP 1 — IMMEDIATE RECOGNITION & STABILIZATION (First 10 Minutes)", bg=RED))
story.append(sp(2))
step1_rows = [
["12-lead ECG", "<b>Within 10 minutes of arrival</b> — paramount to diagnosis"],
["IV Access", "Two large-bore IVs; draw bloods simultaneously"],
["Supplemental O₂", "Only if SpO₂ <90% — avoid routine hyperoxia"],
["Continuous Telemetry", "VF causes ~50% of STEMI deaths — monitor immediately"],
["Portable CXR", "Rule out pulmonary oedema, aortic dissection"],
["Urine Pregnancy Test", "Mandatory in all women of reproductive age"],
["Labs", "Troponin, CBC, aPTT/PT/INR, BMP, Mg²⁺, lipid profile, type & screen"],
]
# render with bold in second col
step1_data = [[Paragraph("Action", cell_hdr), Paragraph("Detail", cell_hdr)]]
for r in step1_rows:
step1_data.append([
Paragraph(r[0], cell_bold),
Paragraph(r[1], cell_body),
])
step1_t = Table(step1_data, colWidths=[CW*0.30, CW*0.70])
step1_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), RED),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(step1_t)
story.append(sp(2))
story.append(alert_box(
"⚠ Do NOT wait for troponin results to initiate reperfusion — ECG + clinical picture is sufficient.",
bg=YELLOW_BG, tc=colors.HexColor("#784212")
))
story.append(sp(3))
# ════════════════ ECG LOCALISATION ══════════════════════════════════════════
story.append(section_box("ECG-BASED TERRITORY LOCALISATION", bg=GREY_DARK))
story.append(sp(2))
ecg_rows = [
["V₁–V₆ or new LBBB", "Anterior + Septal (large)", "Proximal LAD or Left Main"],
["V₂–V₄", "Anterior wall", "LAD"],
["V₅–V₆", "Lateral wall", "LCX"],
["II, III, aVF", "Inferior wall", "RCA or LCX"],
["I, aVL", "High lateral wall", "Diagonal / Proximal LCX"],
["V₁–V₂ depression → get V₇–V₉", "Posterior", "RCA or LCX"],
]
story.append(three_col(
["ST Elevation In", "Territory", "Culprit Artery"],
ecg_rows,
col_w=[CW*0.36, CW*0.32, CW*0.32],
hdr_bg=GREY_DARK
))
story.append(sp(1))
story.append(Paragraph(
"⚠ For <b>inferior STEMI</b>: always obtain right-sided leads (V3R / V4R) — "
"RV infarction changes management (IV fluids, avoid nitrates).",
S("_inf", fontSize=7.5, textColor=DARK_RED, fontName="Helvetica-Bold", leading=10)
))
story.append(sp(3))
# ════════════════ STEP 2 ════════════════════════════════════════════════════
story.append(section_box("STEP 2 — UPSTREAM MEDICAL THERAPY (Give Immediately)", bg=BLUE))
story.append(sp(2))
# Antiplatelets
story.append(Paragraph("DUAL ANTIPLATELET THERAPY (DAPT)", S("_sh2", fontSize=8.5,
fontName="Helvetica-Bold", textColor=BLUE, leading=11)))
story.append(sp(1))
apt_rows = [
["<b>Aspirin (ASA)</b>", "162–325 mg chewed/crushed", "81 mg/day indefinitely"],
["<b>Ticagrelor</b> (preferred for PCI)", "180 mg loading", "90 mg twice daily + ASA 81 mg"],
["<b>Prasugrel</b> (alt for PCI)", "60 mg loading", "10 mg/day — Avoid if >75y, <60kg, stroke/TIA"],
["<b>Clopidogrel</b> (if fibrinolysis)", "300–600 mg loading", "75 mg/day"],
]
apt_data = [[Paragraph("Drug", cell_hdr), Paragraph("Loading Dose", cell_hdr),
Paragraph("Maintenance / Notes", cell_hdr)]]
for r in apt_rows:
apt_data.append([Paragraph(c, cell_body) for c in r])
apt_t = Table(apt_data, colWidths=[CW*0.30, CW*0.25, CW*0.45])
apt_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), BLUE),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(apt_t)
story.append(sp(2))
# Anticoagulation
story.append(Paragraph("ANTICOAGULATION", S("_sh3", fontSize=8.5,
fontName="Helvetica-Bold", textColor=BLUE, leading=11)))
story.append(sp(1))
ac_rows = [
["<b>UFH</b> (preferred for PCI)", "60 U/kg IV bolus (max 4000 U)\nthen 12 U/kg/h", "PCI or fibrinolysis; real-time monitoring with ACT"],
["<b>Enoxaparin (LMWH)</b>", "30 mg IV bolus → 1 mg/kg SC q12h", "Preferred with fibrinolysis"],
["<b>Bivalirudin</b>", "0.75 mg/kg bolus → 1.75 mg/kg/h", "PCI; agent of choice in HIT; lower bleeding vs GPIIb/IIIa"],
["<b>Fondaparinux</b>", "2.5 mg IV → 2.5 mg SC daily", "Fibrinolysis when no PCI planned"],
]
ac_data = [[Paragraph("Drug", cell_hdr), Paragraph("Dose", cell_hdr),
Paragraph("Notes", cell_hdr)]]
for r in ac_rows:
ac_data.append([Paragraph(c, cell_body) for c in r])
ac_t = Table(ac_data, colWidths=[CW*0.28, CW*0.33, CW*0.39])
ac_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), BLUE),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(ac_t)
story.append(sp(2))
# Anti-ischaemic
story.append(Paragraph("ANTI-ISCHAEMIC THERAPY", S("_sh4", fontSize=8.5,
fontName="Helvetica-Bold", textColor=BLUE, leading=11)))
story.append(sp(1))
ai_rows = [
["<b>Nitroglycerin</b>", "SL or IV infusion (titrate to SBP 100–140)",
"<b>AVOID</b> if: SBP <90, HR >100 or <50, RV infarct, PDE5-inhibitor use in 48h"],
["<b>Morphine</b>", "2–4 mg IV (titrate)",
"Refractory pain only — may mask ischaemic symptoms; use judiciously"],
["<b>Beta-blocker</b> (Metoprolol)", "12.5–25 mg oral q6h",
"<b>AVOID</b> if: HF, cardiogenic shock, bradycardia, or hypotension (SBP <100)"],
]
ai_data = [[Paragraph("Drug", cell_hdr), Paragraph("Dose", cell_hdr),
Paragraph("Notes / Contraindications", cell_hdr)]]
for r in ai_rows:
ai_data.append([Paragraph(c, cell_body) for c in r])
ai_t = Table(ai_data, colWidths=[CW*0.28, CW*0.30, CW*0.42])
ai_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), BLUE),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(ai_t)
story.append(sp(3))
# ════════════════ STEP 3 ════════════════════════════════════════════════════
story.append(section_box("STEP 3 — REPERFUSION STRATEGY (Most Critical Decision)", bg=GREEN))
story.append(sp(2))
# Reperfusion decision flowchart as a table
rep_decision = [
[
# PCI column
Table([
[Paragraph("PRIMARY PCI", S("_pcih", fontSize=9, fontName="Helvetica-Bold",
textColor=WHITE, alignment=TA_CENTER, leading=11))],
[Paragraph("Gold Standard", S("_pcis", fontSize=7.5, textColor=WHITE,
alignment=TA_CENTER, leading=9))],
], colWidths=[(CW-4*mm)*0.5],
style=[("BACKGROUND",(0,0),(-1,-1),GREEN),
("TOPPADDING",(0,0),(-1,-1),4),
("BOTTOMPADDING",(0,0),(-1,-1),4)]),
# Fibrinolysis column
Table([
[Paragraph("FIBRINOLYSIS", S("_fibh", fontSize=9, fontName="Helvetica-Bold",
textColor=WHITE, alignment=TA_CENTER, leading=11))],
[Paragraph("When PCI not available in time", S("_fibs", fontSize=7.5,
textColor=WHITE, alignment=TA_CENTER, leading=9))],
], colWidths=[(CW-4*mm)*0.5],
style=[("BACKGROUND",(0,0),(-1,-1),ORANGE),
("TOPPADDING",(0,0),(-1,-1),4),
("BOTTOMPADDING",(0,0),(-1,-1),4)]),
]
]
rep_hdr = Table(rep_decision, colWidths=[(CW-4*mm)*0.5, (CW-4*mm)*0.5],
style=[("TOPPADDING",(0,0),(-1,-1),0),("BOTTOMPADDING",(0,0),(-1,-1),0),
("LEFTPADDING",(0,0),(-1,-1),2),("RIGHTPADDING",(0,0),(-1,-1),2)])
story.append(rep_hdr)
story.append(sp(1))
rep_body = [
[
# PCI bullets
Table([
[Paragraph("• Door-to-balloon ≤ <b>90 min</b> from first medical contact", cell_body)],
[Paragraph("• Transfer centres: first medical contact to PCI ≤ <b>120 min</b>", cell_body)],
[Paragraph("• Superior vessel patency (TIMI-3), less reinfarction, less ICH", cell_body)],
[Paragraph("• Symptoms <b>12–24 h</b>: PCI still beneficial if ongoing symptoms", cell_body)],
[Paragraph("• <b>Always preferred</b>: cardiogenic shock, severe HF, fibrinolysis CI, uncertain diagnosis", cell_body)],
], colWidths=[(CW-4*mm)*0.5],
style=[("BACKGROUND",(0,0),(-1,-1),GREEN_BG),
("TOPPADDING",(0,0),(-1,-1),2),("BOTTOMPADDING",(0,0),(-1,-1),2),
("LEFTPADDING",(0,0),(-1,-1),5),("RIGHTPADDING",(0,0),(-1,-1),5)]),
# Fibrinolysis bullets
Table([
[Paragraph("• Use when PCI not available within <b>90–120 min</b>", cell_body)],
[Paragraph("• Symptoms onset <b>< 12 hours</b>", cell_body)],
[Paragraph("• Door-to-needle ≤ <b>30 min</b>", cell_body)],
[Paragraph("• After fibrinolysis: transfer for angiography within <b>3–24 h</b>", cell_body)],
[Paragraph("• <b>Rescue PCI</b> if: chest pain persists, <50% ST reduction at 90 min", cell_body)],
], colWidths=[(CW-4*mm)*0.5],
style=[("BACKGROUND",(0,0),(-1,-1),colors.HexColor("#FEF5E7")),
("TOPPADDING",(0,0),(-1,-1),2),("BOTTOMPADDING",(0,0),(-1,-1),2),
("LEFTPADDING",(0,0),(-1,-1),5),("RIGHTPADDING",(0,0),(-1,-1),5)]),
]
]
rep_body_t = Table(rep_body, colWidths=[(CW-4*mm)*0.5, (CW-4*mm)*0.5],
style=[("TOPPADDING",(0,0),(-1,-1),0),("BOTTOMPADDING",(0,0),(-1,-1),0),
("LEFTPADDING",(0,0),(-1,-1),2),("RIGHTPADDING",(0,0),(-1,-1),2),
("VALIGN",(0,0),(-1,-1),"TOP")])
story.append(rep_body_t)
story.append(sp(2))
# ── Fibrinolytic agents ───────────────────────────────────────────────────────
story.append(Paragraph("FIBRINOLYTIC AGENTS", S("_fib_hdr", fontSize=8.5,
fontName="Helvetica-Bold", textColor=ORANGE, leading=11)))
story.append(sp(1))
fib_rows = [
["<b>Tenecteplase (TNK-tPA)</b> ★ Preferred", "0.5 mg/kg IV single bolus (30–50 mg)",
"Single bolus — convenient; equivalent mortality benefit, lowest bleeding"],
["Alteplase (rt-PA)", "15 mg IV bolus → 0.75 mg/kg/30 min → 0.5 mg/kg/60 min", "Fibrin-selective; no allergic reactions"],
["Reteplase (r-PA)", "Two 10-unit IV boluses 30 min apart", "Double bolus; equivalent to rt-PA"],
["Streptokinase", "1.5 million units IV over 60 min", "Cheapest; non-selective; allergic reactions 1–2%; avoid if prior use"],
]
fib_data = [[Paragraph("Agent", cell_hdr), Paragraph("Dose", cell_hdr),
Paragraph("Notes", cell_hdr)]]
for r in fib_rows:
fib_data.append([Paragraph(c, cell_body) for c in r])
fib_t = Table(fib_data, colWidths=[CW*0.30, CW*0.34, CW*0.36])
fib_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), ORANGE),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(fib_t)
story.append(sp(2))
# ── Fibrinolysis contraindications ────────────────────────────────────────────
ci_left = [
"<b>ABSOLUTE CONTRAINDICATIONS</b>",
"Prior intracranial haemorrhage / haemorrhagic stroke",
"Ischaemic stroke within 3 months",
"Known cerebrovascular AVM / aneurysm / tumour",
"Closed head injury within 3 months",
"Active aortic dissection",
"Active bleeding or bleeding diathesis",
"Acute pericarditis",
"SBP >180 or DBP >110 mmHg (uncontrolled)",
]
ci_right = [
"<b>RELATIVE CONTRAINDICATIONS</b>",
"Prior ischaemic stroke >3 months ago",
"Recent internal bleeding (2–4 weeks)",
"Major surgery within 3 weeks",
"Prolonged / traumatic CPR >10 min",
"Active peptic ulcer disease",
"Non-compressible vascular punctures",
"Pregnancy",
"Oral anticoagulant use",
]
ci_rows = []
for i in range(max(len(ci_left), len(ci_right))):
l = ci_left[i] if i < len(ci_left) else ""
r = ci_right[i] if i < len(ci_right) else ""
lc = S("_cil", fontSize=7.5, textColor=DARK_RED if i==0 else BLACK,
fontName="Helvetica-Bold" if i==0 else "Helvetica", leading=10)
rc = S("_cir", fontSize=7.5, textColor=DARK_RED if i==0 else BLACK,
fontName="Helvetica-Bold" if i==0 else "Helvetica", leading=10)
ci_rows.append([Paragraph(l, lc), Paragraph(r, rc)])
ci_t = Table(ci_rows, colWidths=[CW*0.50, CW*0.50])
ci_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(0,-1), colors.HexColor("#FDEDEC")),
("BACKGROUND", (1,0),(1,-1), colors.HexColor("#FEF9E7")),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 2), ("BOTTOMPADDING",(0,0),(-1,-1), 2),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(Paragraph("CONTRAINDICATIONS TO FIBRINOLYSIS", S("_ci_hdr", fontSize=8.5,
fontName="Helvetica-Bold", textColor=DARK_RED, leading=11)))
story.append(sp(1))
story.append(ci_t)
story.append(sp(2))
# ── Signs of successful reperfusion ──────────────────────────────────────────
rep_signs = [
"Relief of chest pain / angina",
">50% reduction in ST-segment elevation at 90 minutes",
"Reperfusion arrhythmia (accelerated idioventricular rhythm)",
]
story.append(Paragraph("SIGNS OF SUCCESSFUL REPERFUSION", S("_rep_hdr", fontSize=8.5,
fontName="Helvetica-Bold", textColor=GREEN, leading=11)))
story.append(sp(1))
story.append(bullet_table(rep_signs, bg=GREEN_BG))
story.append(sp(3))
# ════════════════ STEP 4 — POST-STEMI THERAPY ════════════════════════════
story.append(section_box("STEP 4 — POST-STEMI LONG-TERM MEDICAL THERAPY", bg=DARK_RED))
story.append(sp(2))
post_rows = [
["<b>Aspirin (ASA)</b>", "81 mg/day", "Indefinitely"],
["<b>P2Y12 Inhibitor (DAPT)</b>", "Ticagrelor 90 mg BD OR Clopidogrel 75 mg/day", "Minimum <b>12 months</b>"],
["<b>Beta-blocker</b>", "Metoprolol succinate (titrate up)", "Indefinitely — start within 24 h"],
["<b>ACE Inhibitor</b>", "Captopril 6.25 mg → titrate OR Ramipril", "All patients; within 24 h; EF <40% derives most benefit"],
["<b>ARB</b>", "Valsartan / Losartan", "If ACE-I intolerant"],
["<b>High-intensity Statin</b>", "Atorvastatin 40–80 mg OR Rosuvastatin 20–40 mg",
"Target LDL <70 mg/dL or ≥50% reduction; add PCSK9i / ezetimibe if needed"],
["<b>Aldosterone Antagonist</b>", "Eplerenone / Spironolactone", "EF <40% + HF or diabetes; caution in hyperkalaemia / renal impairment"],
]
post_data = [[Paragraph("Drug Class", cell_hdr), Paragraph("Agent / Dose", cell_hdr),
Paragraph("Duration / Notes", cell_hdr)]]
for r in post_rows:
post_data.append([Paragraph(c, cell_body) for c in r])
post_t = Table(post_data, colWidths=[CW*0.25, CW*0.37, CW*0.38])
post_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), DARK_RED),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(post_t)
story.append(sp(3))
# ════════════════ KEY TIME TARGETS ══════════════════════════════════════════
story.append(section_box("KEY TIME TARGETS — AHA/ACC", bg=colors.HexColor("#117A65")))
story.append(sp(2))
time_data = [
[Paragraph("Target", cell_hdr), Paragraph("Time", cell_hdr), Paragraph("Notes", cell_hdr)],
[Paragraph("ECG from patient arrival", cell_body),
Paragraph("<b>≤ 10 min</b>", S("_tm1",fontSize=8,fontName="Helvetica-Bold",
textColor=DARK_RED,leading=10)),
Paragraph("Paramount — initiate MI protocol immediately", cell_body)],
[Paragraph("Door-to-balloon (PCI at same centre)", cell_body),
Paragraph("<b>≤ 90 min</b>", S("_tm2",fontSize=8,fontName="Helvetica-Bold",
textColor=DARK_RED,leading=10)),
Paragraph("From first medical contact", cell_body)],
[Paragraph("First medical contact to PCI (transfer)", cell_body),
Paragraph("<b>≤ 120 min</b>", S("_tm3",fontSize=8,fontName="Helvetica-Bold",
textColor=DARK_RED,leading=10)),
Paragraph("Transfer if PCI achievable within this window", cell_body)],
[Paragraph("Door-to-needle (fibrinolysis)", cell_body),
Paragraph("<b>≤ 30 min</b>", S("_tm4",fontSize=8,fontName="Helvetica-Bold",
textColor=DARK_RED,leading=10)),
Paragraph("If PCI not available within 90–120 min window", cell_body)],
[Paragraph("Symptom onset — fibrinolysis benefit", cell_body),
Paragraph("<b>< 12 h</b>", S("_tm5",fontSize=8,fontName="Helvetica-Bold",
textColor=DARK_RED,leading=10)),
Paragraph("Greatest benefit in first 3 hours", cell_body)],
]
time_t = Table(time_data, colWidths=[CW*0.40, CW*0.20, CW*0.40])
time_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), colors.HexColor("#117A65")),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
("ALIGN", (1,0),(1,-1), "CENTER"),
]))
story.append(time_t)
story.append(sp(3))
# ════════════════ CCU / PERI-INFARCT CARE ══════════════════════════════════
story.append(section_box("CCU ADMISSION ORDERS & MONITORING", bg=GREY_DARK))
story.append(sp(2))
ccu_items = [
"Admit to CCU / coronary care with continuous telemetry for ≥24 hours",
"Vital signs q1h until stable; notify if HR >100 or <50, SBP <90 or >150, SpO₂ <90%",
"Activity: bed rest >12 h; light activity when stable and pain-free",
"Diet: NPO (sips of water) until pain-free; then 2 g sodium heart-healthy diet",
"Serial ECGs daily; assess for recurrent chest pain, new murmurs, HF signs",
"Baseline echocardiogram: document EF, wall motion, valvular lesions, LV thrombus",
"Pacing readiness: AV block in anterior MI is unstable — requires temporary then permanent pacemaker",
"Stool softener, anxiolytic/hypnotic as needed",
]
story.append(bullet_table(ccu_items, bg=BLUE_BG))
story.append(sp(3))
# ════════════════ COMPLICATIONS TO WATCH ═══════════════════════════════════
story.append(section_box("MECHANICAL COMPLICATIONS TO WATCH", bg=colors.HexColor("#6C3483")))
story.append(sp(2))
comp_rows = [
["<b>Free wall rupture</b>", "Sudden haemodynamic collapse, tamponade", "Emergency surgery — mortality 90%"],
["<b>VSD (papillary / septal)</b>","New harsh pan-systolic murmur + haemodynamic deterioration", "Emergency surgery / percutaneous closure"],
["<b>Papillary muscle rupture</b>","Sudden pulmonary oedema, new mitral regurgitation murmur", "Emergency mitral valve surgery"],
["<b>RV infarction</b>", "Inferior STEMI + hypotension + JVD + clear lungs", "IV fluids, avoid nitrates / diuretics"],
["<b>LV thrombus</b>", "EF <40%, anterior MI — echocardiography", "Anticoagulation 3–6 months"],
["<b>Ventricular fibrillation</b>","Accounts for ~50% early STEMI mortality", "Immediate defibrillation; telemetry mandatory"],
]
comp_data = [[Paragraph("Complication", cell_hdr), Paragraph("Presentation", cell_hdr),
Paragraph("Management", cell_hdr)]]
for r in comp_rows:
comp_data.append([Paragraph(c, cell_body) for c in r])
comp_t = Table(comp_data, colWidths=[CW*0.27, CW*0.37, CW*0.36])
comp_t.setStyle(TableStyle([
("BACKGROUND", (0,0),(-1,0), colors.HexColor("#6C3483")),
("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY_BG]),
("GRID", (0,0),(-1,-1), 0.4, colors.HexColor("#BFC9CA")),
("TOPPADDING", (0,0),(-1,-1), 3), ("BOTTOMPADDING",(0,0),(-1,-1), 3),
("LEFTPADDING", (0,0),(-1,-1), 5), ("RIGHTPADDING", (0,0),(-1,-1), 5),
("VALIGN", (0,0),(-1,-1), "MIDDLE"),
]))
story.append(comp_t)
story.append(sp(3))
# ════════════════ FOOTER ════════════════════════════════════════════════════
story.append(HRFlowable(width=CW, thickness=0.5, color=GREY_DARK))
story.append(sp(1))
story.append(Paragraph(
"Sources: The Washington Manual of Medical Therapeutics • Goldman-Cecil Medicine • "
"Fuster & Hurst's The Heart 15E • AHA/ACC STEMI Guidelines | "
"Generated by Orris Clinical AI • For clinical decision support only — always apply individual patient judgement.",
footer_s
))
# ── BUILD ──────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")
Running Command
cd /home/daytona/workspace/stemi-pdf && python3 create_stemi_pdf.py 2>&1
Running Command
ls -lh /home/daytona/workspace/stemi-pdf/STEMI_ED_Algorithm.pdf
Running Command
python3 -c " from pypdf import PdfReader r = PdfReader('/home/daytona/workspace/…
Your STEMI ED Algorithm PDF is ready - 3 pages, fully formatted for clinical quick reference.
STEMI ED Algorithm
PDF Document · PDF
What's Inside (3 pages):
| Section | Content |
|---|---|
| Banner + Key Principle | Time-is-muscle alert with mortality stats |
| Step 1 - Immediate Stabilization | 10-minute actions, O2, IV, telemetry, labs table |
| ECG Territory Localisation | 6-lead territory/coronary artery table + RV infarct warning |
| Step 2 - Upstream Medical Therapy | DAPT table (aspirin/ticagrelor/prasugrel/clopidogrel) + anticoagulation table (UFH/LMWH/bivalirudin) + anti-ischaemic drugs |
| Step 3 - Reperfusion Strategy | PCI vs Fibrinolysis side-by-side with time targets, fibrinolytic agents (TNK preferred), absolute/relative contraindications to thrombolysis, signs of successful reperfusion |
| Step 4 - Post-STEMI Therapy | Long-term drug table (ASA, P2Y12, BB, ACEi, statin, aldosterone antagonist) |
| Key Time Targets | All AHA/ACC targets in one colour-coded table |
| CCU Admission Orders | Monitoring, diet, activity, pacing guidance |
| Mechanical Complications | Free wall rupture, VSD, papillary rupture, RV infarct, LV thrombus, VF |
| Footer | Source citations |
Management of Non STEMI
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Here is the full, structured NSTEMI/UA management guide:
Management of NSTEMI / Unstable Angina (UA)
Key distinction from STEMI: NSTEMI involves incomplete coronary occlusion with subendocardial ischemia. There is no immediate mandatory reperfusion window - the priority is risk stratification, antithrombotic therapy, and timing the invasive strategy appropriately.
Definition & Key Differences
| Feature | UA | NSTEMI |
|---|---|---|
| Troponin | Negative | Positive (myocardial necrosis) |
| ECG | No persistent ST elevation | No ST elevation; may have depression, T-wave inversion |
| Mechanism | Partial occlusion, no necrosis | Partial occlusion + necrosis |
| Mortality | Lower short-term | Higher short-term than UA, similar long-term to STEMI |
Approximately 70% of all ACS presentations are NSTEMI/UA. At 1 year: ~6% death, ~11% recurrent MI, ~50-60% need revascularization.
STEP 1 - Immediate Assessment & Diagnosis
ECG (within 10 minutes)
- ~50% of NSTEMI/UA patients have significant ECG changes
- ST depression ≥0.5 mm in V2-V3 or ≥1 mm in other leads = myocardial ischemia
- ST depression in multiple leads + ST elevation in aVR/V1 = left main or multivessel disease (high risk)
- Wellens syndrome (biphasic or deeply inverted T waves in V2-V4 + QT prolongation) = critical proximal LAD lesion - do NOT stress test; go straight to angiography
- Serial ECGs to detect dynamic changes
Biomarkers
- High-sensitivity Troponin (hsTn): at 0h, 1h, 3h - most sensitive/specific marker
- CK-MB no longer recommended as initial diagnostic marker
- BNP elevation in ACS = large infarct, worse prognosis, consider urgent angiography
STEP 2 - Risk Stratification
TIMI Risk Score (1 point each = 7 total)
| Criterion | 1 Point |
|---|---|
| Age >65 years | ✓ |
| Known CAD (stenosis >50%) | ✓ |
| ≥2 angina episodes in 24 hours | ✓ |
| ST-segment or T-wave changes | ✓ |
| Elevated cardiac biomarkers | ✓ |
| Aspirin use in last 7 days | ✓ |
| ≥3 CAD risk factors (family hx, DM, HTN, hyperlipidaemia, smoking) | ✓ |
Score 0-1: Low risk (~4%) | Score 2: ~7% | Score 3-4: ~12-19% | Score 5: ~26% | Score 6-7: ~41% (14-day death, MI, or urgent revascularization)
STEP 3 - Invasive Strategy Selection
| Strategy | Timing | Indications |
|---|---|---|
| Immediate/Urgent Invasive | <2 hours (like STEMI) | Refractory angina; haemodynamic instability/shock; new HF/MR; sustained VT or VF |
| Early Invasive | <24 hours | TIMI ≥3 or GRACE >140; rapid troponin rise; new ST depressions |
| Delayed Invasive | 24-72 hours | Diabetes; renal insufficiency (GFR <60); EF <40%; prior PCI <6 months; prior CABG; TIMI ≥2 or GRACE 109-140 |
| Ischaemia-Driven (Conservative) | No routine angio | Low risk (TIMI ≤1, GRACE <109); low-risk biomarker-negative females; patient preference |
In the ischaemia-driven approach: if no high-risk features develop, perform non-invasive stress testing - must be angina-free ≥12 hours prior. Proceed to angiography if high-risk stress test, LVEF <40%, or recurrent symptoms.
STEP 4 - Medical Therapy (All Patients, All Strategies)
Anti-Ischaemic Therapy
| Drug | Dose | Notes |
|---|---|---|
| Nitroglycerin (SL) | 0.3-0.6 mg SL q5 min x3 | First-line for ischaemic pain |
| Nitroglycerin (IV) | 5-10 µg/min, increase by 10 µg/min q3-5 min (max 200 µg/min) | For recurrent angina, uncontrolled HTN, or HF; avoid if SBP <90, PDE5 inhibitor use within 24-48h, RV infarct |
| Beta-blocker (Metoprolol) | Target HR 50-60 bpm (oral preferred) | Start early; avoid if acute/severe HF, low cardiac output, bradycardia, heart block, active bronchospasm |
| Calcium channel blocker (Diltiazem/Verapamil) | Per dosing | If persistent ischaemia despite full-dose nitrates + BB, or if BB contraindicated |
| Morphine | 1-5 mg IV q5-30 min | Refractory severe pain only; use judiciously - may mask symptoms |
| O2 | Titrate to SpO2 ≥90% | Only if hypoxaemic - routine O2 is not indicated |
Antiplatelet Therapy (DAPT - Mandatory)
| Drug | Loading Dose | Maintenance | Notes |
|---|---|---|---|
| Aspirin (ASA) | 162-325 mg chewed | 75-100 mg/day indefinitely | First-line; give immediately |
| Ticagrelor (preferred) | 180 mg | 90 mg twice daily (≤100 mg ASA) | Superior to clopidogrel; higher bleeding; avoid if prior intracranial haemorrhage |
| Prasugrel | 60 mg | 10 mg/day | Only for PCI; avoid if >75y, <60kg, history of stroke/TIA |
| Clopidogrel | 300-600 mg | 75 mg/day | Use if ticagrelor/prasugrel unavailable or contraindicated |
| GPIIb/IIIa inhibitors (eptifibatide, tirofiban) | Per protocol | Infusion | Reserve for high thrombus burden during PCI or thrombotic PCI complications - not routine |
DAPT duration: Minimum 12 months regardless of revascularization. May shorten to 3-6 months in high bleeding risk + low ischaemic risk patients.
Anticoagulation
| Drug | Dose | Notes |
|---|---|---|
| UFH | 60 U/kg IV bolus (max 4000 U) → 12 U/kg/h (aPTT 1.5-2x normal) | Standard for PCI; easy to reverse |
| Enoxaparin (LMWH) | 1 mg/kg SC q12h | Preferred with fibrinolysis; continue until discharge or up to 8 days |
| Bivalirudin | 0.75 mg/kg bolus → 1.75 mg/kg/h | PCI alternative; choice in HIT; lower bleeding |
| Fondaparinux | 2.5 mg SC daily | Conservative strategy; least bleeding risk; do NOT use alone at PCI (risk of catheter thrombosis) |
Anticoagulation should be initiated in all NSTEMI/UA patients regardless of chosen strategy.
STEP 5 - Long-Term Secondary Prevention
| Drug | Target/Duration | Notes |
|---|---|---|
| Aspirin 75-100 mg | Indefinitely | |
| P2Y12 inhibitor (ticagrelor or prasugrel preferred over clopidogrel) | 12 months minimum | Extend >12 months in high thrombotic risk; reduce ticagrelor to 60 mg BD after 1 year |
| Beta-blocker | Indefinitely | |
| ACE inhibitor / ARB | Indefinitely | All ACS patients; especially EF <40%, DM, HTN |
| High-intensity statin | LDL <55 mg/dL (ESC) or LDL <70 mg/dL (ACC/AHA); ≥50% reduction | Atorvastatin 80 mg or Rosuvastatin 40 mg; add ezetimibe or PCSK9 inhibitor if target not reached |
| SGLT2 inhibitor / GLP-1 RA | Per indication | In patients with type 2 diabetes; cardiovascular outcome benefit |
| Aldosterone antagonist | EF <40% + HF or DM | Eplerenone/Spironolactone |
LDL target: ESC 2023 guidelines recommend <55 mg/dL with ≥50% reduction from baseline for very high-risk patients (post-ACS). - Harrison's 22E (2025)
Key Differences: NSTEMI vs STEMI Management
| Feature | STEMI | NSTEMI/UA |
|---|---|---|
| Reperfusion urgency | Immediate (door-to-balloon ≤90 min) | Risk-stratified (urgent only if haemodynamically unstable) |
| Fibrinolysis | Yes (if PCI unavailable) | No - fibrinolysis not indicated |
| DAPT | Immediate | Immediate |
| Anticoagulation | Yes | Yes |
| Timing of angiography | Immediate | 2h / 24h / 72h based on risk |
Special Notes
- Women with NSTEMI/UA have worse short- and long-term outcomes and are undertreated - ensure equal application of guideline-directed therapy
- Wellens syndrome (critical LAD lesion) - ECG may be normal or show T-wave changes between episodes; do not stress test; proceed to urgent angiography
- ST depression multivessel pattern + aVR elevation = left main disease - treat as very high risk
- If triple therapy (ASA + P2Y12 + anticoagulant for AF): keep triple therapy duration minimal; stop ASA at discharge or 1 week, continue anticoagulant + clopidogrel until month 12, then anticoagulant alone
Sources: The Washington Manual of Medical Therapeutics; Harrison's Principles of Internal Medicine 22E (2025); Goldman-Cecil Medicine
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