from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, HRFlowable, ListFlowable, ListItem
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY

OUTPUT = "/home/daytona/workspace/cardio-questions/Cardiovascular_QA.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=2*cm,
    leftMargin=2*cm,
    topMargin=2*cm,
    bottomMargin=2*cm,
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    "DocTitle",
    parent=styles["Title"],
    fontSize=18,
    spaceAfter=8,
    textColor=colors.HexColor("#1a3c5e"),
    alignment=TA_CENTER,
    fontName="Helvetica-Bold",
)

section_heading = ParagraphStyle(
    "SectionHeading",
    parent=styles["Heading1"],
    fontSize=14,
    spaceBefore=18,
    spaceAfter=6,
    textColor=colors.HexColor("#1a3c5e"),
    fontName="Helvetica-Bold",
    borderPad=4,
)

q_style = ParagraphStyle(
    "Question",
    parent=styles["Normal"],
    fontSize=10.5,
    spaceBefore=12,
    spaceAfter=4,
    fontName="Helvetica-Bold",
    textColor=colors.HexColor("#2c2c2c"),
    leftIndent=0,
)

ans_style = ParagraphStyle(
    "Answer",
    parent=styles["Normal"],
    fontSize=10,
    spaceBefore=2,
    spaceAfter=4,
    fontName="Helvetica",
    leading=15,
    leftIndent=12,
    textColor=colors.HexColor("#1a1a1a"),
    alignment=TA_JUSTIFY,
)

sub_heading = ParagraphStyle(
    "SubHeading",
    parent=styles["Normal"],
    fontSize=10.5,
    spaceBefore=6,
    spaceAfter=2,
    fontName="Helvetica-Bold",
    textColor=colors.HexColor("#1a3c5e"),
    leftIndent=12,
)

bullet_style = ParagraphStyle(
    "Bullet",
    parent=styles["Normal"],
    fontSize=10,
    spaceBefore=1,
    spaceAfter=1,
    fontName="Helvetica",
    leftIndent=24,
    bulletIndent=14,
    leading=14,
)

story = []

# ─── TITLE ────────────────────────────────────────────────────────────────────
story.append(Paragraph("Cardiovascular System", title_style))
story.append(Paragraph("Question & Answer Notes", ParagraphStyle(
    "Sub", parent=styles["Normal"], fontSize=11, alignment=TA_CENTER,
    textColor=colors.HexColor("#555555"), spaceAfter=10
)))
story.append(HRFlowable(width="100%", thickness=2, color=colors.HexColor("#1a3c5e"), spaceAfter=14))


def H(text):
    story.append(Paragraph(text, section_heading))
    story.append(HRFlowable(width="100%", thickness=0.8, color=colors.HexColor("#aac4e0"), spaceAfter=6))

def Q(text):
    story.append(Paragraph(f"Q. {text}", q_style))

def A(text):
    story.append(Paragraph(text, ans_style))

def SH(text):
    story.append(Paragraph(text, sub_heading))

def B(items):
    for item in items:
        story.append(Paragraph(f"• {item}", bullet_style))

def SP():
    story.append(Spacer(1, 6))

# ══════════════════════════════════════════════════════════════════════════════
#  SECTION 1: CHEST PAIN
# ══════════════════════════════════════════════════════════════════════════════
H("1. Chest Pain")

# Q1 — Causes and approach to diagnosis
Q("A 50-year-old man is admitted with central chest pain of a few hours duration. List the possible causes. How will you arrive at a diagnosis?")

SH("Possible Causes of Central Chest Pain:")
B([
    "Cardiac: Acute Myocardial Infarction (AMI), Unstable Angina, Stable Angina, Myocarditis, Pericarditis",
    "Aortic: Aortic dissection",
    "Pulmonary: Pulmonary embolism, Pleuritis, Pneumonia, Pneumothorax",
    "Gastrointestinal: GERD, Esophageal spasm, Peptic ulcer, Pancreatitis",
    "Musculoskeletal: Costochondritis (Tietze syndrome), Rib fracture",
    "Others: Anxiety/panic attack, Herpes zoster (pre-eruptive)",
])

SH("Approach to Diagnosis:")
A("<b>History:</b> Character (crushing/burning/tearing), onset, radiation (to jaw, left arm, back), duration, aggravating/relieving factors (rest, nitrates), associated features (sweating, nausea, dyspnea, palpitations).")
A("<b>Examination:</b> BP both arms, pulse, JVP, heart sounds, pericardial rub, lung fields, chest wall tenderness.")
A("<b>Investigations:</b>")
B([
    "ECG (12-lead): ST elevation/depression, T-wave inversion, new LBBB → AMI; saddle-shaped ST rise → pericarditis; S1Q3T3 → PE",
    "Cardiac Biomarkers: Troponin I/T (gold standard for MI; rise at 3–6 hrs, peak 12–24 hrs); CK-MB (useful for re-infarction); Myoglobin (earliest, non-specific)",
    "Chest X-ray: cardiomegaly, widened mediastinum (dissection), pleural effusion, pneumothorax",
    "Echocardiography: wall motion abnormalities, pericardial effusion, aortic root",
    "D-dimer + CT-PA: if PE suspected",
    "CT Aortogram: if aortic dissection suspected",
    "ABG: hypoxia in PE/pneumothorax",
])
SP()

# Q2 — Diagnosis of MI + Management
Q("A patient with severe chest pain is brought to emergency. What investigations would you do to reach the diagnosis? How would you manage a case of MI with chest pain of less than 4 hours duration?")

SH("Investigations to Diagnose MI:")
B([
    "12-lead ECG: STEMI (ST elevation ≥1mm in ≥2 contiguous leads or new LBBB); NSTEMI (ST depression, T inversion, or normal)",
    "Serum Troponin I or T: Rises 3–6 hrs after infarct; highly sensitive and specific",
    "CK-MB: Rises at 4–6 hrs, peaks 12–24 hrs; useful for re-infarction",
    "FBC: Leucocytosis in AMI",
    "LFTs, RFTs, Blood glucose (baseline before thrombolysis)",
    "Chest X-ray: pulmonary edema, cardiomegaly",
    "Echocardiogram: regional wall motion abnormality confirms ischemia/infarct",
])

SH("Management of Acute STEMI (< 4 hours):")
A("<b>Immediate (MONA + Antiplatelet):</b>")
B([
    "M — Morphine 2–4 mg IV (pain relief, preload reduction)",
    "O — Oxygen: Only if SpO₂ < 94%",
    "N — Nitrates: Sublingual GTN (avoid if hypotension or RV infarct)",
    "A — Aspirin 300 mg stat (loading dose) + Clopidogrel 300–600 mg (or Ticagrelor 180 mg)",
])
A("<b>Reperfusion Therapy — Preferred:</b>")
B([
    "Primary PCI (percutaneous coronary intervention) — gold standard if available within 90 min (door-to-balloon time <90 min); angioplasty ± stenting",
    "Thrombolysis if PCI not available within 120 min: Streptokinase 1.5 MU IV over 60 min, or tPA (Alteplase), or Tenecteplase",
])
A("<b>Anticoagulation:</b> Heparin (UFH IV or LMWH e.g. Enoxaparin) — adjunct to PCI/thrombolysis.")
A("<b>Other drugs:</b>")
B([
    "Beta-blockers (Metoprolol) — reduce infarct size, arrhythmias; avoid in cardiogenic shock",
    "ACE inhibitors (Ramipril) — started within 24 hrs if BP stable; prevent LV remodelling",
    "Statins (Atorvastatin 40–80 mg) — start immediately for plaque stabilization",
    "Proton pump inhibitor — gastroprotection with dual antiplatelet therapy",
])
A("<b>Monitoring:</b> Continuous ECG monitoring, BP, SpO₂, urine output, repeat troponin at 3–6 hrs.")
SP()

# Q3 — DD of chest pain
Q("List the differential diagnosis of chest pain.")
B([
    "Acute Myocardial Infarction",
    "Unstable/Stable Angina",
    "Aortic Dissection",
    "Pulmonary Embolism",
    "Pericarditis / Myocarditis",
    "Pneumothorax",
    "Pneumonia / Pleuritis",
    "GERD / Esophageal spasm",
    "Costochondritis (Tietze syndrome)",
    "Peptic ulcer / Pancreatitis",
    "Panic disorder / Anxiety",
    "Herpes zoster (pre-eruptive phase)",
])
SP()

# ══════════════════════════════════════════════════════════════════════════════
#  SECTION 2: INFECTIVE ENDOCARDITIS
# ══════════════════════════════════════════════════════════════════════════════
H("2. Infective Endocarditis")

Q("Discuss clinical manifestations, etiology, pathogenesis, and treatment of acute bacterial endocarditis.")

SH("Definition:")
A("Infective endocarditis (IE) is a microbial infection of the endocardial surface of the heart, most commonly affecting the valves (native or prosthetic).")

SH("Etiology:")
A("<b>Most common organisms:</b>")
B([
    "Staphylococcus aureus — most common in acute IE and IV drug users; most virulent",
    "Viridans streptococci (S. sanguis, S. mitis) — most common in subacute IE; associated with dental procedures",
    "Enterococcus faecalis — GI/GU procedures",
    "S. epidermidis (CONS) — prosthetic valve endocarditis",
    "HACEK organisms (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) — culture-negative, fastidious",
    "Streptococcus bovis (gallolyticus) — associated with colorectal carcinoma",
    "Fungi (Candida) — IV drug users, immunocompromised, prosthetic valves",
])

SH("Predisposing Factors:")
B([
    "Rheumatic heart disease (most common in developing countries)",
    "Congenital heart disease (VSD, bicuspid aortic valve, PDA)",
    "Prosthetic heart valves",
    "IV drug abuse",
    "Intravascular devices (central lines, pacemakers)",
    "Poor dental hygiene / dental procedures",
    "Prior endocarditis",
    "Mitral valve prolapse (with regurgitation)",
])

SH("Pathogenesis:")
A("Damaged endothelium → platelet-fibrin thrombus (non-bacterial thrombotic endocarditis) → bacteremia → bacterial adherence → vegetation formation (fibrin, platelets, bacteria). Vegetations lead to: local valve destruction, septic emboli, immune complex deposition.")

SH("Clinical Manifestations:")
A("<b>Symptoms:</b> Fever (most common, >90%), chills, malaise, weight loss, night sweats, dyspnea, new murmur.")
A("<b>Peripheral Stigmata (immune complex / embolic phenomena):</b>")
B([
    "Osler nodes — painful, tender nodules on finger/toe pads (immune complex)",
    "Janeway lesions — painless hemorrhagic macules on palms/soles (septic emboli)",
    "Splinter hemorrhages — linear dark streaks under nails",
    "Roth spots — retinal hemorrhages with pale centers (fundoscopy)",
    "Clubbing — in chronic IE",
    "Petechiae — conjunctival, mucosal",
])
A("<b>Cardiac:</b> New or changing murmur (most important sign), heart failure due to valve destruction.")
A("<b>Embolic phenomena:</b> Stroke, renal infarcts, splenic infarcts, mycotic aneurysm, septic pulmonary emboli (right-sided IE in IV drug users).")
A("<b>Splenomegaly</b> and microscopic haematuria (immune complex nephritis).")

SH("Duke Criteria (Diagnosis):")
A("<b>Major criteria:</b> (1) Positive blood culture (typical organisms × 2, or persistent bacteremia); (2) Echocardiographic evidence of IE (vegetation, abscess, dehiscence of prosthetic valve).")
A("<b>Minor criteria:</b> Predisposing condition, fever >38°C, vascular phenomena, immunologic phenomena (Osler nodes, Roth spots, positive RF), single positive blood culture.")
A("Definite IE: 2 major, OR 1 major + 3 minor, OR 5 minor criteria.")

SH("Investigations:")
B([
    "Blood cultures × 3 sets (aerobic + anaerobic, from different sites, before antibiotics) — most important",
    "Echocardiogram: TTE (transthoracic) first; TEE (transesophageal) if TTE negative but high suspicion — detects vegetations, abscess, valvular regurgitation",
    "FBC: anaemia (normochromic, normocytic), leucocytosis",
    "ESR and CRP: elevated",
    "Urinalysis: microscopic haematuria, proteinuria (immune complex nephritis)",
    "Serum creatinine, LFTs",
    "Rheumatoid factor: positive in ~50%",
    "Complement levels (C3, C4): decreased in immune complex disease",
    "ECG: new PR prolongation (aortic root abscess), arrhythmias",
    "CXR: pulmonary infiltrates (septic emboli in right-sided IE), cardiac enlargement",
    "CT/MRI brain: cerebral emboli/abscess",
])

SH("Treatment:")
A("<b>Empirical antibiotic therapy</b> (after blood cultures):")
B([
    "Native valve, community-acquired: Ampicillin-sulbactam + Gentamicin (or Vancomycin + Gentamicin if MRSA risk)",
    "Prosthetic valve / hospital-acquired: Vancomycin + Rifampicin + Gentamicin",
])
A("<b>Specific therapy (based on culture):</b>")
B([
    "Viridans Streptococci (penicillin-sensitive): Penicillin G 12–18 MU/day IV × 4 weeks, OR Ceftriaxone 2g/day × 4 weeks",
    "Staphylococcus aureus (MSSA): Flucloxacillin/Nafcillin IV × 4–6 weeks",
    "MRSA: Vancomycin 15 mg/kg IV 12-hourly × 6 weeks",
    "Enterococcus: Ampicillin + Gentamicin × 4–6 weeks (or Vancomycin if resistant)",
    "HACEK: Ceftriaxone 2g/day × 4 weeks",
    "Fungal IE: Amphotericin B + surgical valve replacement",
])
A("<b>Surgical Indications:</b>")
B([
    "Refractory heart failure due to valve destruction",
    "Uncontrolled infection (persisting bacteremia, abscess, fungal IE)",
    "Prevention of emboli (large vegetation >10 mm, recurrent emboli)",
    "Prosthetic valve dehiscence",
])
A("<b>Prophylaxis:</b> Amoxicillin 2g PO (or Ampicillin 2g IV) 30–60 min before invasive dental procedures in high-risk patients (prosthetic valves, prior IE, unrepaired cyanotic CHD, cardiac transplant with valvulopathy). Penicillin-allergic: Clindamycin 600mg (now replaced by Doxycycline per 2021 AHA update).")

SP()

# Culture-negative endocarditis
Q("Write short notes on: Culture-negative bacterial endocarditis.")
A("<b>Definition:</b> IE in which blood cultures remain negative after 5–7 days incubation despite clinical and echocardiographic evidence of IE (~5–15% of all IE cases).")
SH("Causes:")
B([
    "Prior antibiotic therapy (most common cause — suppresses growth)",
    "Fastidious organisms: HACEK group, Nutritionally variant streptococci (Abiotrophia)",
    "Obligate intracellular organisms: Coxiella burnetii (Q fever), Bartonella, Brucella, Chlamydia",
    "Fungi: Candida, Aspergillus",
    "Marantic (non-bacterial thrombotic) endocarditis — SLE, malignancy",
    "Libman-Sacks endocarditis — SLE (antiphospholipid antibodies)",
])
SH("Diagnosis:")
B([
    "Prolonged incubation of blood cultures (up to 4 weeks)",
    "Serological tests: Coxiella phase I IgG (Q fever), Bartonella IgG, Brucella serology",
    "PCR on blood, valve tissue, or embolic material",
    "16S rRNA sequencing of valve tissue",
    "TEE echocardiography",
    "PET-CT scan (increased uptake at valve)",
])
SH("Treatment:")
A("Based on identified organism. If Coxiella: Doxycycline + Hydroxychloroquine for ≥18 months. If Bartonella: Doxycycline + Aminoglycoside.")
SP()

# ══════════════════════════════════════════════════════════════════════════════
#  SECTION 3: CORONARY ARTERY DISEASE AND ANGINA
# ══════════════════════════════════════════════════════════════════════════════
H("3. Coronary Artery Disease and Angina")

Q("Discuss the clinical manifestations, investigations, and management of angina pectoris. Define angina pectoris and discuss anti-anginal drugs.")

SH("Definition:")
A("Angina pectoris is a clinical syndrome characterized by episodic chest pain or pressure due to transient myocardial ischemia, caused by a mismatch between myocardial oxygen supply and demand, most commonly due to atherosclerotic coronary artery disease.")

SH("Types:")
B([
    "Stable angina: Predictable, precipitated by exertion/stress, relieved by rest or GTN within 5 min",
    "Unstable angina: New onset, occurring at rest, increasing in frequency/severity; medical emergency (part of ACS)",
    "Variant (Prinzmetal) angina: Coronary artery spasm, occurs at rest, ST elevation during attack",
    "Angina equivalent: Dyspnea, fatigue, diaphoresis without chest pain (common in elderly, diabetics, women)",
])

SH("Clinical Manifestations:")
A("<b>Typical features:</b> Central, retrosternal chest tightness/pressure/heaviness; radiation to left arm, jaw, neck, back; lasts 2–10 min; precipitated by exertion, cold, emotion, meals; relieved by rest and GTN.")
A("<b>Associated features:</b> Dyspnea, diaphoresis, nausea, palpitations.")
A("<b>CCS Grading:</b> Class I–IV based on level of activity causing angina.")

SH("Investigations:")
B([
    "Resting ECG: May be normal; ST depression, T-wave inversion during attack",
    "Exercise (treadmill) stress test (EST): ST depression ≥1 mm at 80 mV with exercise — gold standard for stable angina",
    "Echocardiogram (stress echo): Regional wall motion abnormalities during pharmacological stress",
    "Coronary Angiography: Gold standard to define coronary anatomy; ≥70% stenosis is significant",
    "CT Coronary Angiography (CTCA): Non-invasive assessment of coronary anatomy",
    "Nuclear myocardial perfusion scan (SPECT/PET): Perfusion defects in ischemic territories",
    "Cardiac biomarkers: Troponin normal in stable angina (elevated in NSTEMI/unstable angina)",
    "FBC, lipid profile, fasting glucose, HbA1c (risk factor assessment)",
])

SH("Management of Stable Angina:")
A("<b>General / Non-pharmacological:</b>")
B([
    "Risk factor modification: Stop smoking, treat hypertension, diabetes, hyperlipidaemia",
    "Weight reduction, regular aerobic exercise, dietary modification",
    "Cardiac rehabilitation",
])
A("<b>Pharmacological — Anti-anginal drugs:</b>")
A("<b>1. Nitrates:</b>")
B([
    "Short-acting: Sublingual GTN (glyceryl trinitrate) 0.5 mg — acute relief; onset 1–2 min",
    "Long-acting: Isosorbide mononitrate/dinitrate — prophylaxis; given with nitrate-free interval (8–12 hrs) to prevent tolerance",
    "Mechanism: Release of NO → venodilation → reduced preload → reduced myocardial O₂ demand; also dilate coronary arteries",
])
A("<b>2. Beta-blockers (first-line):</b>")
B([
    "Atenolol, Metoprolol, Bisoprolol, Carvedilol",
    "Mechanism: Reduce heart rate and contractility → reduce myocardial O₂ demand",
    "Reduce angina frequency and improve exercise tolerance; also cardioprotective post-MI",
    "Contraindicated in asthma, severe bradycardia, Prinzmetal angina",
])
A("<b>3. Calcium Channel Blockers (CCBs):</b>")
B([
    "Dihydropyridines (Amlodipine, Nifedipine): Vasodilation; used with beta-blockers or if beta-blockers contraindicated",
    "Non-dihydropyridines (Verapamil, Diltiazem): Reduce HR and contractility; alternative to beta-blockers",
    "Drug of choice in Prinzmetal (vasospastic) angina",
])
A("<b>4. Antiplatelet therapy:</b>")
B([
    "Aspirin 75 mg daily — reduces risk of MI and cardiovascular events (mandatory in all CAD patients)",
    "Clopidogrel — if aspirin intolerant, or as dual antiplatelet after PCI",
])
A("<b>5. Statins (mandatory):</b> Atorvastatin 40–80 mg or Rosuvastatin; reduce plaque progression and CV events.")
A("<b>6. ACE inhibitors:</b> Ramipril — reduce risk in patients with diabetes, LV dysfunction, or hypertension.")
A("<b>7. Newer anti-anginal drugs:</b>")
B([
    "Ranolazine: Inhibits late Na+ current → reduces diastolic wall tension; for refractory angina",
    "Ivabradine: Inhibits If (funny) channel in SA node → reduces HR without affecting BP/contractility; for HR >70 bpm when beta-blockers contraindicated",
    "Nicorandil: Potassium channel opener + nitrate; dual action; reduces preload and afterload",
    "Trimetazidine: Metabolic agent; shifts metabolism from fatty acid to glucose oxidation",
])
A("<b>Revascularization:</b>")
B([
    "Percutaneous Coronary Intervention (PCI): For single or double vessel disease; balloon angioplasty + drug-eluting stent",
    "Coronary Artery Bypass Grafting (CABG): For triple vessel disease, left main stem disease, or diabetes with multi-vessel disease",
])

Q("Briefly outline the management of unstable angina.")
A("<b>Unstable Angina (UA)</b> is part of Acute Coronary Syndrome (ACS) — requires urgent hospitalization.")
B([
    "Admit, bed rest, continuous ECG monitoring",
    "O₂ if SpO₂ < 94%",
    "Antiplatelet: Aspirin 300 mg + Ticagrelor 180 mg (or Clopidogrel 300 mg) stat",
    "Anticoagulation: Fondaparinux 2.5 mg SC/day OR Enoxaparin 1 mg/kg SC 12-hourly",
    "Anti-ischemic: Sublingual/IV nitrates, Beta-blocker, Morphine (if pain severe)",
    "Statin: Atorvastatin 80 mg immediately",
    "Risk stratification (GRACE or TIMI score) → determine timing of angiography",
    "Early invasive strategy (angiography ± PCI within 24–72 hrs) for high-risk NSTEMI/UA",
    "GPIIb/IIIa inhibitors (Tirofiban, Eptifibatide) if ongoing ischemia before PCI",
])

Q("Write short notes on: Acute coronary syndrome (ACS).")
A("<b>ACS</b> is a spectrum of ischemic heart disease caused by sudden reduction of coronary blood flow due to plaque rupture/erosion + thrombus formation.")
SH("Classification:")
B([
    "STEMI: ST elevation on ECG + positive troponin — complete occlusion of coronary artery",
    "NSTEMI: No ST elevation, positive troponin — partial occlusion",
    "Unstable angina: No ST elevation, negative troponin — threatened infarction",
])
A("<b>Common presentation:</b> Severe chest pain at rest, radiation to left arm/jaw, sweating, nausea, dyspnea, anxiety.")
A("<b>Management:</b> MONA protocol, antiplatelet (aspirin + P2Y12 inhibitor), anticoagulation, beta-blockers, statins, ACE inhibitors, reperfusion (primary PCI preferred for STEMI within 12 hrs).")

Q("Write short notes on: Angina equivalent.")
A("Angina equivalent refers to symptoms of myocardial ischemia that occur without typical chest pain. Commonly seen in elderly patients, diabetics (due to autonomic neuropathy), women, and post-cardiac transplant patients.")
B([
    "Exertional dyspnoea (most common equivalent)",
    "Unexplained fatigue",
    "Diaphoresis",
    "Epigastric discomfort or nausea",
    "Syncope or presyncope",
    "Palpitations",
])
A("These patients have the same prognosis as those with typical angina and require the same evaluation and management.")
SP()

# ══════════════════════════════════════════════════════════════════════════════
#  SECTION 4: MYOCARDIAL INFARCTION
# ══════════════════════════════════════════════════════════════════════════════
H("4. Myocardial Infarction")

Q("Enumerate the risk factors of coronary artery disease. How will you diagnose a case of acute myocardial infarction? Outline the management of acute MI. Mention its complications.")

SH("Risk Factors of Coronary Artery Disease:")
A("<b>Modifiable:</b>")
B([
    "Hypertension",
    "Dyslipidaemia (high LDL, low HDL, high triglycerides)",
    "Diabetes mellitus and insulin resistance",
    "Smoking (most powerful modifiable risk factor)",
    "Obesity (BMI >30)",
    "Physical inactivity",
    "Unhealthy diet (high saturated fat, refined carbohydrates)",
    "Metabolic syndrome",
    "Chronic kidney disease",
    "Psychological stress / Type A personality",
])
A("<b>Non-modifiable:</b>")
B([
    "Age: >45 years in men; >55 years in women (post-menopausal)",
    "Male sex",
    "Family history: First-degree relative with premature CAD (<55 M, <65 F)",
    "Ethnicity: South Asians at highest risk",
])
A("<b>Novel/Emerging:</b> High Lp(a), homocysteine, CRP, thrombogenic factors.")

SH("Diagnosis of Acute MI:")
A("<b>1. Clinical criteria:</b> Acute onset severe chest pain (>20 min), radiation to left arm/jaw, sweating, nausea, vomiting, anxiety, sense of doom.")
A("<b>2. ECG changes (STEMI):</b>")
B([
    "Hyperacute T waves (earliest change, minutes)",
    "ST elevation ≥1 mm in ≥2 contiguous leads (or ≥2 mm in V1-V4) — within minutes",
    "Pathological Q waves (>0.04 sec, >25% of QRS height) — permanent scar; appear at 6–12 hrs",
    "T wave inversion — subacute phase",
    "NSTEMI: ST depression ≥0.5 mm, T wave inversion, or normal ECG with positive troponin",
])
A("<b>Localisation by ECG:</b>")
B([
    "Inferior MI: ST elevation in II, III, aVF (RCA occlusion)",
    "Anterior MI: ST elevation in V1–V4 (LAD occlusion)",
    "Lateral MI: ST elevation in I, aVL, V5–V6 (LCx occlusion)",
    "Posterior MI: ST depression V1–V2 with tall R waves (reciprocal changes)",
])
A("<b>3. Cardiac Biomarkers:</b>")
B([
    "Troponin I/T: Rise at 3–6 hrs, peak 12–24 hrs, persist 7–14 days — most specific and sensitive",
    "CK-MB: Rise 4–6 hrs, peak 12–24 hrs, normalise 48–72 hrs — useful for re-infarction detection",
    "Myoglobin: Earliest (1–3 hrs) but not specific",
    "LDH: Rises at 24–48 hrs, persists 10–14 days — useful in late presentations",
])
A("<b>4. Imaging:</b> Echocardiogram — wall motion abnormality; Coronary angiography — confirms occlusion.")

SH("Management of Acute MI:")
A("<b>A. Immediate (first 10 minutes):</b>")
B([
    "IV access, continuous ECG, SpO₂, BP monitoring",
    "O₂ only if SpO₂ < 94%",
    "Aspirin 300 mg + Ticagrelor 180 mg (or Clopidogrel 300 mg) — dual antiplatelet",
    "Morphine IV (pain, anxiety, preload reduction)",
    "IV nitrates (if SBP >90 mmHg, no RV infarct)",
    "12-lead ECG — repeat if STEMI evolving",
])
A("<b>B. Reperfusion for STEMI:</b>")
B([
    "Primary PCI: First choice; door-to-balloon time <90 min (or <120 min if transferred); drug-eluting stent preferred",
    "Thrombolysis (fibrinolysis): If PCI unavailable within 120 min of first medical contact",
    "- Streptokinase 1.5 MU IV over 60 min (not reused — antigenic)",
    "- tPA (Alteplase), Tenecteplase, Reteplase — fibrin-specific; preferred",
    "- Contraindications: Prior stroke, active bleeding, recent surgery, severe hypertension (>180/110), aortic dissection",
    "Anticoagulation with PCI: Unfractionated heparin IV bolus or Bivalirudin",
    "Anticoagulation with thrombolysis: Enoxaparin or UFH for minimum 48 hrs",
])
A("<b>C. Adjunctive medical therapy:</b>")
B([
    "Beta-blocker: Metoprolol 25–50 mg (within 24 hrs if stable; reduces arrhythmias, infarct size, mortality)",
    "ACE inhibitor: Ramipril 2.5–10 mg (within 24 hrs; prevents LV remodelling, reduces heart failure risk)",
    "Statin: Atorvastatin 40–80 mg (start immediately; plaque stabilization)",
    "Proton pump inhibitor: With dual antiplatelets",
    "Aldosterone antagonist (Eplerenone): If EF <40% + HF or diabetes (post-MI)",
])
A("<b>D. Long-term / Secondary prevention:</b>")
B([
    "Aspirin 75 mg indefinitely + Clopidogrel/Ticagrelor for 12 months",
    "Beta-blocker for minimum 1 year (lifelong if EF reduced)",
    "ACE inhibitor/ARB lifelong",
    "Statin lifelong (target LDL < 1.4 mmol/L or 55 mg/dL)",
    "Cardiac rehabilitation",
    "Lifestyle modifications: smoking cessation, diet, exercise, weight loss",
])

SH("Complications of Acute MI:")
A("<b>Early (< 48 hours):</b>")
B([
    "Arrhythmias: VF (most common cause of early death), VT, AF, heart block (inferior MI — AV block), sinus bradycardia",
    "Cardiogenic shock: SBP < 90 mmHg, cool extremities, oliguria — mortality ~50%",
    "Acute LV failure / pulmonary oedema",
    "Papillary muscle rupture → acute mitral regurgitation (harsh pansystolic murmur)",
    "Free wall rupture → haemopericardium and cardiac tamponade",
    "Ventricular septal defect (VSD) — post-MI, harsh pansystolic murmur",
    "Right ventricular infarction (inferior MI with ST elevation in V4R)",
])
A("<b>Late (days–weeks):</b>")
B([
    "Dressler syndrome (post-MI syndrome): Fever, pericarditis, pleuritis; occurs 2–10 weeks post-MI; treat with NSAIDs/aspirin",
    "Left ventricular aneurysm: Persistent ST elevation, arrhythmias, thrombus with embolism",
    "Thromboembolism: Mural thrombus → stroke, systemic emboli",
    "Chronic heart failure with reduced EF (HFrEF)",
    "Sudden cardiac death (SCD)",
])

Q("Write the diagnosis and management of acute anterior wall STEMI of a 53-year-old diabetic male patient.")
A("A 53-year-old diabetic male presenting with acute chest pain, diaphoresis, and dyspnea is a high-risk STEMI patient due to diabetes (blunted symptoms, worse prognosis).")
A("<b>Diagnosis:</b>")
B([
    "ECG: ST elevation in leads V1–V4 (anterior MI; LAD occlusion)",
    "Urgent serum Troponin I/T (elevated within 3–6 hrs)",
    "Echocardiogram: Anterior wall motion abnormality, assess LV function (EF)",
    "FBC, RFT (contrast use for PCI), blood glucose, HbA1c",
    "Chest X-ray: pulmonary oedema, cardiomegaly",
])
A("<b>Management:</b>")
B([
    "Activate cardiac catheterization lab immediately — Primary PCI is treatment of choice",
    "Aspirin 300 mg + Ticagrelor 180 mg (avoid Clopidogrel in diabetics — poorer response; Ticagrelor preferred)",
    "Anticoagulation: Heparin IV or Bivalirudin",
    "Reperfusion: Primary PCI with drug-eluting stent to LAD",
    "Blood glucose management: Target 7.8–10 mmol/L acutely; avoid hypoglycaemia; insulin infusion if needed",
    "Beta-blocker, ACE inhibitor, Statin (atorvastatin 80 mg)",
    "Monitor for complications: Cardiogenic shock (more common in anterior MI), arrhythmias (VF), acute HF",
    "Long-term: DAPT (aspirin + ticagrelor) × 12 months, lifelong statin and ACE-I, cardiac rehab",
])

Q("Short notes: Risk factors for ischaemic heart disease.")
A("See risk factors for CAD enumerated above (Modifiable and Non-modifiable factors).")
B([
    "Most important modifiable: Smoking, hypertension, dyslipidaemia, diabetes",
    "Smoking doubles the risk of MI; cessation reduces risk to near-normal in 5 years",
    "Diabetes doubles the risk of CAD in men and quadruples it in women",
    "Hypertension increases risk proportionally to level of BP",
    "Dyslipidaemia: LDL > 3 mmol/L, HDL < 1 mmol/L (M) / 1.2 mmol/L (F) significantly increases risk",
    "Framingham Risk Score is the standard tool for 10-year cardiovascular risk assessment",
])

# ─── BUILD PDF ─────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")