Guideline to start statin for opd patients

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Finding Sources

Searching PubMed

statin therapy initiation guidelines cardiovascular risk

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Finding Sources

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Searching the Web

2024 ACC AHA statin guidelines primary prevention OPD outpatient indications

Excellent - I now have strong data from Harrison's 22E (2025), Current Surgical Therapy, and the brand-new 2026 ACC/AHA dyslipidemia guideline. Let me compile the comprehensive answer.

Guidelines for Starting Statin Therapy in Outpatients (OPD)

Based on the 2018 AHA/ACC and updated 2026 ACC/AHA Dyslipidemia Guidelines, along with current textbook evidence from Harrison's 22E (2025), statin initiation is guided by four patient groups:

Group 1: Established ASCVD (Secondary Prevention) - STRONGEST INDICATION

Start HIGH-INTENSITY statin - no risk calculator needed.

Includes any of the following:

Acute coronary syndrome (ACS), MI (past or recent)
Stable or unstable angina
Coronary/peripheral arterial revascularization
Ischemic stroke or TIA
Peripheral artery disease (PAD), aortic aneurysm

Goal: LDL-C reduction ≥50% (target LDL-C <70 mg/dL; <55 mg/dL if very high risk)

"Patients with clinical ASCVD... are recommended to begin high-intensity statin therapy with an aim of achieving a 50% or greater reduction in LDL-C levels." - Current Surgical Therapy 14e

Group 2: LDL-C ≥190 mg/dL (Familial Hypercholesterolemia or Severe Hypercholesterolemia)

Start HIGH-INTENSITY statin regardless of calculated risk.

Treat early, even in young adults
Consider additional agents (ezetimibe, PCSK9 inhibitors) if LDL-C target not met
Family history should lower threshold for initiation

Group 3: Diabetes Mellitus (Age 40-75) - PRIMARY PREVENTION

Start statin therapy regardless of baseline LDL-C or 10-year risk score.

Use moderate-intensity statin as default
Escalate to high-intensity if 10-year ASCVD risk ≥10% or other risk factors present
In patients <40 or >75 years with DM: use clinical judgment

Group 4: Primary Prevention - Based on 10-Year Cardiovascular Risk (Age 30-79, No ASCVD)

This group requires risk calculator before starting therapy.

2026 Update: Use PREVENT-ASCVD Equations (replaced older Pooled Cohort Equations)

Applies to adults aged 30-79 without known ASCVD or subclinical atherosclerosis, with LDL-C 70-189 mg/dL.

10-Year PREVENT Risk	Recommendation
<3%	Lifestyle modification only; statin generally not indicated
3% to <5% (borderline)	LDL-lowering therapy is reasonable after clinician-patient discussion
5% to <10% (intermediate)	Statin recommended after risk discussion
≥10% (high)	Statin strongly recommended

Harrison's 22E (2025): "Current guidelines suggest that a 10-year risk >7.5% merits consideration of statin therapy regardless of plasma LDL-C level."

Risk-Enhancing Factors (Tilt Borderline/Intermediate Cases Toward Starting)

When the decision to start is uncertain, these factors push toward initiating therapy:

Family history of premature ASCVD (<55 in males, <65 in females)
LDL-C ≥160 mg/dL or non-HDL-C ≥190 mg/dL
Chronic kidney disease (CKD)
Metabolic syndrome
Inflammatory conditions (RA, psoriasis, HIV)
Premature menopause, pre-eclampsia history
Elevated Lp(a) ≥50 mg/dL
Elevated hs-CRP ≥2 mg/L
Elevated ApoB ≥130 mg/dL
Coronary Artery Calcium (CAC) score - men >40, women >50:
- CAC = 0: consider withholding statin (very low risk)
- CAC ≥100: favor initiating statin

Statin Intensity Classification

Intensity	LDL-C Reduction	Examples
High	≥50%	Atorvastatin 40-80 mg, Rosuvastatin 20-40 mg
Moderate	30-49%	Atorvastatin 10-20 mg, Rosuvastatin 5-10 mg, Simvastatin 20-40 mg
Low	<30%	Simvastatin 10 mg, Pravastatin 10-20 mg

Before Starting - Baseline Workup

Fasting lipid panel (LDL-C, HDL-C, TG, total cholesterol)
LFTs (ALT/AST) - baseline, not needed routinely after
CK (baseline if high myopathy risk)
Fasting glucose / HbA1c (statin slightly increases DM risk - counsel patient)
PREVENT-ASCVD 10-year risk calculation (for primary prevention)

Key Points on Safety / Monitoring

Routine CK monitoring not needed unless symptoms arise
Statin can mildly elevate transaminases - usually transient, not a reason to stop
Statin-associated myalgia occurs in ~3-5%; true myopathy is rare
Risk of myopathy increases with: advanced age, renal insufficiency, drug interactions (macrolides, antifungals, gemfibrozil, cyclosporine)
A small excess risk of new-onset T2DM exists but cardiovascular benefits far outweigh this risk
If LDL-C target not met on maximum statin: add ezetimibe first, then consider PCSK9 inhibitor

When NOT to Start (or Use Caution)

Active liver disease or persistent unexplained transaminase elevation
Pregnancy or breastfeeding (teratogenic - absolutely contraindicated)
Rhabdomyolysis history with statins
Age >75 years without established ASCVD - individualize (less clear benefit)

Sources: Harrison's Principles of Internal Medicine 22E (2025); Current Surgical Therapy 14e; 2026 ACC/AHA Dyslipidemia Guideline (the most current guideline as of 2026, which introduced PREVENT-ASCVD equations)

Create a statin selection flowchart/decision tree for your clinic

Reading File

Running Command

ls /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/statin-flowchart

Writing File

~/statin-flowchart/build.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3 x 7.5 inches

// ── Colour palette ────────────────────────────────────────────────────────────
const C = {
  navy:    "0B2545",   // dominant dark
  teal:    "1B6CA8",   // secondary
  sky:     "4DA6D9",   // light blue accent
  green:   "2E8B57",   // YES / go
  amber:   "D4870A",   // intermediate / caution
  red:     "C0392B",   // high risk / stop
  white:   "FFFFFF",
  offWhite:"F4F8FC",
  grey:    "7F8C8D",
  lightGrey:"E8EFF5",
  yellow:  "FFF3CD",
  darkGrey:"2C3E50",
};

// ── Helper: rounded box ───────────────────────────────────────────────────────
function box(slide, {x, y, w, h, fill, line, lineW, radius, shadow}) {
  slide.addShape(pres.ShapeType.roundRect, {
    x, y, w, h,
    fill: { color: fill || C.white },
    line: { color: line || "CCCCCC", width: lineW || 1 },
    rectRadius: radius !== undefined ? radius : 0.08,
    shadow: shadow || null,
  });
}

// ── Helper: centred label inside a box ───────────────────────────────────────
function label(slide, text, {x, y, w, h, color, fontSize, bold, italic, wrap}) {
  slide.addText(text, {
    x, y, w, h,
    fontSize: fontSize || 11,
    color: color || C.white,
    bold: bold !== undefined ? bold : true,
    italic: italic || false,
    align: "center",
    valign: "middle",
    wrap: wrap !== undefined ? wrap : true,
    margin: 4,
  });
}

// ── Helper: diamond shape ─────────────────────────────────────────────────────
function diamond(slide, {x, y, w, h, fill, line}) {
  // Approximate with rotated rectangle using addShape if available, else use lines
  slide.addShape(pres.ShapeType.diamond, {
    x, y, w, h,
    fill: { color: fill || C.amber },
    line: { color: line || C.navy, width: 1.5 },
  });
}

// ── Helper: arrow connector (horizontal) ─────────────────────────────────────
function arrowH(slide, x1, y, x2, color) {
  slide.addShape(pres.ShapeType.line, {
    x: x1, y, w: x2 - x1, h: 0,
    line: { color: color || C.navy, width: 1.5, endArrowType: "arrow" },
  });
}

// ── Helper: arrow connector (vertical) ───────────────────────────────────────
function arrowV(slide, x, y1, y2, color) {
  slide.addShape(pres.ShapeType.line, {
    x, y: y1, w: 0, h: y2 - y1,
    line: { color: color || C.navy, width: 1.5, endArrowType: "arrow" },
  });
}

function arrowLabel(slide, text, {x, y, fontSize, color}) {
  slide.addText(text, {
    x, y, w: 0.5, h: 0.22,
    fontSize: fontSize || 8,
    color: color || C.green,
    bold: true,
    align: "center",
    margin: 0,
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – COVER
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();

  // Full dark background
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color: C.navy } });

  // Decorative teal accent bar (left)
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:0.18, h:7.5, fill:{ color: C.sky } });

  // Top accent strip
  s.addShape(pres.ShapeType.rect, { x:0.18, y:0, w:13.12, h:0.12, fill:{ color: C.teal } });

  // Main title
  s.addText("Statin Selection", {
    x:0.5, y:1.5, w:12.3, h:1.4,
    fontSize:52, color:C.white, bold:true, align:"center",
    charSpacing:4,
  });

  // Subtitle
  s.addText("Clinical Decision Flowchart for Outpatient Practice", {
    x:0.5, y:3.1, w:12.3, h:0.7,
    fontSize:22, color:C.sky, bold:false, align:"center",
  });

  // Divider line
  s.addShape(pres.ShapeType.line, {
    x:2, y:4.0, w:9.3, h:0,
    line:{ color:C.teal, width:1.5 },
  });

  // Footer info
  s.addText("Based on 2026 ACC/AHA Dyslipidemia Guidelines  |  Harrison's Principles of Internal Medicine 22E", {
    x:0.5, y:4.2, w:12.3, h:0.4,
    fontSize:11, color:C.grey, align:"center",
  });

  // Badge chips
  const badges = ["Primary Prevention", "Secondary Prevention", "Statin Intensity", "Special Populations"];
  badges.forEach((b, i) => {
    const bx = 1.5 + i * 2.7;
    s.addShape(pres.ShapeType.roundRect, {
      x:bx, y:5.0, w:2.3, h:0.38,
      fill:{ color:C.teal }, line:{ color:C.sky, width:1 },
      rectRadius:0.12,
    });
    s.addText(b, {
      x:bx, y:5.0, w:2.3, h:0.38,
      fontSize:9.5, color:C.white, bold:true, align:"center", valign:"middle",
    });
  });

  // Bottom strip
  s.addShape(pres.ShapeType.rect, { x:0, y:7.2, w:13.3, h:0.3, fill:{ color:C.teal } });
  s.addText("OPD / Outpatient Clinic  |  For Educational Use", {
    x:0, y:7.2, w:13.3, h:0.3,
    fontSize:8, color:C.white, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – MAIN FLOWCHART  (landscape decision tree)
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();

  // Background
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.offWhite } });

  // Header bar
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:0.55, fill:{ color:C.navy } });
  s.addText("STATIN INITIATION DECISION FLOWCHART  — OPD", {
    x:0, y:0, w:13.3, h:0.55,
    fontSize:13, color:C.white, bold:true, align:"center", valign:"middle", charSpacing:2,
  });

  // ── START node ──────────────────────────────────────────────────────────
  const startX=5.65, startY=0.65, startW=2, startH=0.42;
  s.addShape(pres.ShapeType.ellipse, {
    x:startX, y:startY, w:startW, h:startH,
    fill:{ color:C.navy }, line:{ color:C.sky, width:2 },
  });
  s.addText("NEW OPD PATIENT", {
    x:startX, y:startY, w:startW, h:startH,
    fontSize:8.5, color:C.white, bold:true, align:"center", valign:"middle",
  });

  // Arrow: start → Q1
  arrowV(s, 6.65, 1.07, 1.32);

  // ── Q1: Established ASCVD? ───────────────────────────────────────────────
  const q1x=5.3, q1y=1.32, q1w=2.7, q1h=0.62;
  diamond(s, { x:q1x, y:q1y, w:q1w, h:q1h, fill:C.amber, line:C.navy });
  s.addText("Established ASCVD?", {
    x:q1x, y:q1y, w:q1w, h:q1h,
    fontSize:10, color:C.navy, bold:true, align:"center", valign:"middle",
  });

  // YES → left → Secondary Prevention box
  arrowH(s, q1x, q1y + q1h/2, q1x - 0.05, C.green);
  // Arrow going left
  s.addShape(pres.ShapeType.line, {
    x:2.15, y:q1y+q1h/2, w:q1x-2.15, h:0,
    line:{ color:C.green, width:2, endArrowType:"arrow" },
  });
  arrowLabel(s, "YES", { x:2.6, y:q1y+q1h/2-0.22, fontSize:9, color:C.green });

  // ── Box A: Secondary Prevention (HIGH intensity) ──────────────────────
  const ax=0.2, ay=1.1, aw=1.95, ah=1.05;
  s.addShape(pres.ShapeType.roundRect, {
    x:ax, y:ay, w:aw, h:ah,
    fill:{ color:C.red }, line:{ color:"8B0000", width:2 }, rectRadius:0.1,
    shadow:{ type:"outer", color:"00000033", blur:4, offset:2, angle:45 },
  });
  s.addText([
    { text:"HIGH INTENSITY", options:{ breakLine:true, bold:true, fontSize:11, color:C.yellow } },
    { text:"STATIN", options:{ breakLine:true, bold:true, fontSize:11, color:C.white } },
    { text:"Secondary Prevention", options:{ breakLine:false, bold:false, fontSize:8, color:"FFCCCC" } },
  ], { x:ax, y:ay, w:aw, h:ah, align:"center", valign:"middle", margin:4 });

  // Sub-box: ACS labels
  s.addShape(pres.ShapeType.roundRect, {
    x:0.18, y:ay+ah+0.08, w:1.98, h:0.85,
    fill:{ color:"FDF2F2" }, line:{ color:C.red, width:1 }, rectRadius:0.06,
  });
  s.addText([
    { text:"• ACS / MI / Angina\n• Stroke / TIA\n• Revascularization\n• PAD / Aortic Aneurysm", options:{ fontSize:7.5, color:C.darkGrey } },
  ], { x:0.22, y:ay+ah+0.1, w:1.9, h:0.8, valign:"top", margin:3 });

  // Target label
  s.addShape(pres.ShapeType.roundRect, {
    x:0.18, y:ay+ah+0.08+0.85+0.06, w:1.98, h:0.38,
    fill:{ color:"2E8B57" }, line:{ color:"1A5C38", width:1 }, rectRadius:0.06,
  });
  s.addText("Target LDL-C < 70 mg/dL\n(≥50% reduction)", {
    x:0.18, y:ay+ah+0.08+0.85+0.06, w:1.98, h:0.38,
    fontSize:7.5, color:C.white, bold:true, align:"center", valign:"middle",
  });

  // NO → down → Q2
  arrowV(s, 6.65, q1y+q1h, 2.25, C.navy);
  arrowLabel(s, "NO", { x:6.7, y:1.78, fontSize:9, color:C.red });

  // ── Q2: LDL ≥ 190? ───────────────────────────────────────────────────────
  const q2x=5.3, q2y=2.25, q2w=2.7, q2h=0.62;
  diamond(s, { x:q2x, y:q2y, w:q2w, h:q2h, fill:C.amber, line:C.navy });
  s.addText("LDL-C ≥ 190 mg/dL?", {
    x:q2x, y:q2y, w:q2w, h:q2h,
    fontSize:10, color:C.navy, bold:true, align:"center", valign:"middle",
  });

  // YES → right → FH/severe box
  s.addShape(pres.ShapeType.line, {
    x:q2x+q2w, y:q2y+q2h/2, w:11.0-(q2x+q2w), h:0,
    line:{ color:C.red, width:2, endArrowType:"arrow" },
  });
  arrowLabel(s, "YES", { x:9.5, y:q2y+q2h/2-0.22, fontSize:9, color:C.green });

  // ── Box B: FH / Severe (right side) ──────────────────────────────────────
  const bx=11.0, by=1.9, bw=2.1, bh=1.05;
  s.addShape(pres.ShapeType.roundRect, {
    x:bx, y:by, w:bw, h:bh,
    fill:{ color:C.red }, line:{ color:"8B0000", width:2 }, rectRadius:0.1,
    shadow:{ type:"outer", color:"00000033", blur:4, offset:2, angle:45 },
  });
  s.addText([
    { text:"HIGH INTENSITY\n", options:{ bold:true, fontSize:10.5, color:C.yellow, breakLine:true } },
    { text:"STATIN", options:{ bold:true, fontSize:10.5, color:C.white, breakLine:true } },
    { text:"FH / Severe Hyperlipid.", options:{ bold:false, fontSize:7.5, color:"FFCCCC" } },
  ], { x:bx, y:by, w:bw, h:bh, align:"center", valign:"middle", margin:4 });

  s.addShape(pres.ShapeType.roundRect, {
    x:bx, y:by+bh+0.08, w:bw, h:0.7,
    fill:{ color:"FDF2F2" }, line:{ color:C.red, width:1 }, rectRadius:0.06,
  });
  s.addText("• FH (familial hypercholest.)\n• Age-independent\n• Add ezetimibe if needed\n• Consider PCSK9i if LDL ↑↑", {
    x:bx+0.05, y:by+bh+0.1, w:bw-0.1, h:0.65,
    fontSize:7.5, color:C.darkGrey, valign:"top", margin:3,
  });

  // NO → down → Q3
  arrowV(s, 6.65, q2y+q2h, 3.15, C.navy);
  arrowLabel(s, "NO", { x:6.7, y:2.7, fontSize:9, color:C.red });

  // ── Q3: Diabetes (40-75y)? ────────────────────────────────────────────────
  const q3x=5.3, q3y=3.15, q3w=2.7, q3h=0.62;
  diamond(s, { x:q3x, y:q3y, w:q3w, h:q3h, fill:C.amber, line:C.navy });
  s.addText("Diabetes Mellitus\n(Age 40-75 yrs)?", {
    x:q3x, y:q3y, w:q3w, h:q3h,
    fontSize:9.5, color:C.navy, bold:true, align:"center", valign:"middle",
  });

  // YES → left → DM statin box
  s.addShape(pres.ShapeType.line, {
    x:2.85, y:q3y+q3h/2, w:q3x-2.85, h:0,
    line:{ color:C.green, width:2, endArrowType:"arrow" },
  });
  arrowLabel(s, "YES", { x:3.4, y:q3y+q3h/2-0.22, fontSize:9, color:C.green });

  // ── Box C: Diabetes ───────────────────────────────────────────────────────
  const cx=0.85, cy=2.9, cw=2.0, ch=1.0;
  s.addShape(pres.ShapeType.roundRect, {
    x:cx, y:cy, w:cw, h:ch,
    fill:{ color:C.teal }, line:{ color:"104E8B", width:2 }, rectRadius:0.1,
    shadow:{ type:"outer", color:"00000033", blur:4, offset:2, angle:45 },
  });
  s.addText([
    { text:"MODERATE\n", options:{ bold:true, fontSize:11, color:C.white, breakLine:true } },
    { text:"INTENSITY STATIN", options:{ bold:true, fontSize:10, color:C.yellow, breakLine:true } },
    { text:"Diabetes", options:{ bold:false, fontSize:8, color:"CCE5FF" } },
  ], { x:cx, y:cy, w:cw, h:ch, align:"center", valign:"middle", margin:4 });

  s.addShape(pres.ShapeType.roundRect, {
    x:cx, y:cy+ch+0.08, w:cw, h:0.62,
    fill:{ color:"F0F8FF" }, line:{ color:C.teal, width:1 }, rectRadius:0.06,
  });
  s.addText("Escalate to HIGH if:\n10-yr risk ≥10%\nor other risk factors", {
    x:cx+0.05, y:cy+ch+0.1, w:cw-0.1, h:0.58,
    fontSize:7.5, color:C.darkGrey, valign:"top", margin:3,
  });

  // NO → down → Q4 (10-yr risk)
  arrowV(s, 6.65, q3y+q3h, 4.05, C.navy);
  arrowLabel(s, "NO", { x:6.7, y:3.62, fontSize:9, color:C.red });

  // ── Q4: Calculate 10-year ASCVD risk ─────────────────────────────────────
  const q4x=4.9, q4y=4.05, q4w=3.5, q4h=0.68;
  s.addShape(pres.ShapeType.roundRect, {
    x:q4x, y:q4y, w:q4w, h:q4h,
    fill:{ color:C.navy }, line:{ color:C.sky, width:2 }, rectRadius:0.1,
  });
  s.addText("Calculate 10-Year ASCVD Risk\n(PREVENT-ASCVD Equation, Age 30-79)", {
    x:q4x, y:q4y, w:q4w, h:q4h,
    fontSize:9, color:C.white, bold:true, align:"center", valign:"middle",
  });

  // Three branches from Q4
  // Low (<3%) → left
  s.addShape(pres.ShapeType.line, {
    x:1.5, y:q4y+q4h/2, w:q4x-1.5, h:0,
    line:{ color:C.green, width:1.5, endArrowType:"arrow" },
  });
  s.addText("< 3%", {
    x:2.0, y:q4y+q4h/2-0.22, w:1.0, h:0.22,
    fontSize:8, color:C.green, bold:true, align:"center",
  });

  // Intermediate (3-<10%) → down
  arrowV(s, 6.65, q4y+q4h, 5.22, C.amber);
  s.addText("3–<10%\n(discuss)", {
    x:6.68, y:q4y+q4h+0.04, w:0.9, h:0.3,
    fontSize:7.5, color:C.amber, bold:true,
  });

  // High (≥10%) → right
  s.addShape(pres.ShapeType.line, {
    x:q4x+q4w, y:q4y+q4h/2, w:10.8-(q4x+q4w), h:0,
    line:{ color:C.red, width:1.5, endArrowType:"arrow" },
  });
  s.addText("≥ 10%", {
    x:9.1, y:q4y+q4h/2-0.22, w:1.0, h:0.22,
    fontSize:8, color:C.red, bold:true, align:"center",
  });

  // ── Box D: LOW risk (<3%) ──────────────────────────────────────────────────
  const dx=0.18, dy=3.88, dw=1.95, dh=0.78;
  s.addShape(pres.ShapeType.roundRect, {
    x:dx, y:dy, w:dw, h:dh,
    fill:{ color:C.green }, line:{ color:"1A5C38", width:2 }, rectRadius:0.1,
  });
  s.addText("LIFESTYLE\nMODIFICATION\nOnly", {
    x:dx, y:dy, w:dw, h:dh,
    fontSize:9.5, color:C.white, bold:true, align:"center", valign:"middle",
  });
  s.addText("Diet, Exercise,\nNo Statin (typically)\nReassess in 5 yrs", {
    x:dx, y:dy+dh+0.05, w:dw, h:0.48,
    fontSize:7.5, color:C.darkGrey, align:"center", bold:false,
  });

  // ── Box E: INTERMEDIATE risk + risk enhancers ─────────────────────────────
  const ex=5.15, ey=5.22, ew=3.0, eh=0.88;
  s.addShape(pres.ShapeType.roundRect, {
    x:ex, y:ey, w:ew, h:eh,
    fill:{ color:C.amber }, line:{ color:"8B5E00", width:2 }, rectRadius:0.1,
    shadow:{ type:"outer", color:"00000033", blur:4, offset:2, angle:45 },
  });
  s.addText("CHECK RISK ENHANCERS\n& Shared Decision Making", {
    x:ex, y:ey, w:ew, h:eh,
    fontSize:9.5, color:C.white, bold:true, align:"center", valign:"middle",
  });

  // Risk enhancer sub-box
  s.addShape(pres.ShapeType.roundRect, {
    x:4.4, y:ey+eh+0.06, w:4.5, h:0.92,
    fill:{ color:C.yellow }, line:{ color:C.amber, width:1 }, rectRadius:0.08,
  });
  s.addText([
    { text:"Risk Enhancers (any 1 → favour statin):  ", options:{ bold:true, fontSize:8, color:C.navy, breakLine:true } },
    { text:"Fam. hx premature ASCVD  •  LDL ≥160  •  CKD  •  hs-CRP ≥2  •  Lp(a) ≥50  •  ApoB ≥130\nMetabolic syndrome  •  Autoimmune disease (RA/Psoriasis/HIV)  •  Premature menopause / Pre-eclampsia", options:{ bold:false, fontSize:7.5, color:C.darkGrey } },
  ], { x:4.45, y:ey+eh+0.08, w:4.4, h:0.86, valign:"top", margin:4 });

  // CAC sub-box
  s.addShape(pres.ShapeType.roundRect, {
    x:4.4, y:ey+eh+0.06+0.92+0.05, w:4.5, h:0.55,
    fill:{ color:"EAF4FF" }, line:{ color:C.sky, width:1 }, rectRadius:0.08,
  });
  s.addText([
    { text:"Coronary Artery Calcium (CAC):  ", options:{ bold:true, fontSize:8, color:C.navy, breakLine:false } },
    { text:"CAC = 0 → withhold  |  CAC 1–99 → consider  |  CAC ≥100 → INITIATE", options:{ bold:false, fontSize:8, color:C.darkGrey } },
  ], { x:4.45, y:ey+eh+0.06+0.92+0.07, w:4.4, h:0.5, valign:"middle", margin:4 });

  // ── Box F: HIGH risk (≥10%) → moderate/high ───────────────────────────────
  const fx=10.8, fy=3.7, fw=2.35, fh=1.1;
  s.addShape(pres.ShapeType.roundRect, {
    x:fx, y:fy, w:fw, h:fh,
    fill:{ color:C.red }, line:{ color:"8B0000", width:2 }, rectRadius:0.1,
    shadow:{ type:"outer", color:"00000033", blur:4, offset:2, angle:45 },
  });
  s.addText([
    { text:"HIGH / MOD-HIGH\n", options:{ bold:true, fontSize:11, color:C.yellow, breakLine:true } },
    { text:"INTENSITY STATIN", options:{ bold:true, fontSize:10, color:C.white, breakLine:true } },
    { text:"Primary Prevention", options:{ bold:false, fontSize:8, color:"FFCCCC" } },
  ], { x:fx, y:fy, w:fw, h:fh, align:"center", valign:"middle", margin:4 });

  s.addShape(pres.ShapeType.roundRect, {
    x:fx, y:fy+fh+0.06, w:fw, h:0.55,
    fill:{ color:"FDF2F2" }, line:{ color:C.red, width:1 }, rectRadius:0.06,
  });
  s.addText("Target ≥50% LDL-C reduction\nTarget LDL-C <100 mg/dL (primary)", {
    x:fx+0.05, y:fy+fh+0.08, w:fw-0.1, h:0.5,
    fontSize:7.5, color:C.darkGrey, valign:"top", margin:3, bold:false,
  });

  // Footer bar
  s.addShape(pres.ShapeType.rect, { x:0, y:7.22, w:13.3, h:0.28, fill:{ color:C.navy } });
  s.addText("2026 ACC/AHA Dyslipidemia Guideline  |  Harrison's 22E  |  For OPD Use", {
    x:0, y:7.22, w:13.3, h:0.28,
    fontSize:7.5, color:C.grey, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – STATIN INTENSITY TABLE
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();

  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.offWhite } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:0.55, fill:{ color:C.navy } });
  s.addText("STATIN INTENSITY GUIDE", {
    x:0, y:0, w:13.3, h:0.55,
    fontSize:15, color:C.white, bold:true, align:"center", valign:"middle", charSpacing:3,
  });

  // Column headers
  const colHeaders = ["Intensity", "LDL-C Reduction", "Statin", "Dose (mg/day)", "Use When"];
  const colX = [0.2, 1.8, 3.6, 6.8, 8.9];
  const colW = [1.5, 1.7, 3.0, 2.0, 4.15];

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      x:colX[i], y:0.65, w:colW[i], h:0.4,
      fontSize:10, color:C.white, bold:true, align:"center", valign:"middle",
    });
  });

  // Data rows
  const rows = [
    {
      intensity: "HIGH",
      color: C.red,
      textColor: C.white,
      reduction: "≥ 50%",
      drugs: [
        { drug:"Atorvastatin", doses:"40 mg, 80 mg" },
        { drug:"Rosuvastatin", doses:"20 mg, 40 mg" },
      ],
      uses:"• Established ASCVD (2° prevention)\n• LDL-C ≥190 mg/dL (FH)\n• DM with 10-yr risk ≥10%\n• Primary prevention, 10-yr risk ≥10%",
    },
    {
      intensity: "MODERATE",
      color: C.amber,
      textColor: C.white,
      reduction: "30–49%",
      drugs: [
        { drug:"Atorvastatin", doses:"10 mg, 20 mg" },
        { drug:"Rosuvastatin", doses:"5 mg, 10 mg" },
        { drug:"Simvastatin", doses:"20 mg, 40 mg" },
        { drug:"Pravastatin", doses:"40 mg, 80 mg" },
        { drug:"Lovastatin", doses:"40 mg" },
        { drug:"Fluvastatin", doses:"40 mg BD / 80 mg XL" },
        { drug:"Pitavastatin", doses:"2 mg, 4 mg" },
      ],
      uses:"• DM age 40-75 (first choice)\n• Primary prevention, 3–<10%\n• Elderly (≥75 y) if treatment indicated\n• Statin-intolerant (try lower dose)",
    },
    {
      intensity: "LOW",
      color: C.green,
      textColor: C.white,
      reduction: "< 30%",
      drugs: [
        { drug:"Simvastatin", doses:"10 mg" },
        { drug:"Pravastatin", doses:"10 mg, 20 mg" },
        { drug:"Lovastatin", doses:"20 mg" },
        { drug:"Fluvastatin", doses:"20–40 mg" },
        { drug:"Pitavastatin", doses:"1 mg" },
      ],
      uses:"• Statin intolerance (titrate up)\n• CKD (adjust as needed)\n• Elderly frail patients\n• Drug interaction concern",
    },
  ];

  let rowY = 1.1;
  rows.forEach((row, ri) => {
    const rowH = ri === 1 ? 2.0 : 1.4;
    const altFill = ri % 2 === 0 ? "F9FBFD" : "EDF3FA";

    // Row background
    s.addShape(pres.ShapeType.rect, { x:0.2, y:rowY, w:12.9, h:rowH, fill:{ color:altFill }, line:{ color:"DDDDDD", width:0.5 } });

    // Intensity badge
    s.addShape(pres.ShapeType.roundRect, {
      x:0.25, y:rowY+0.1, w:1.4, h:rowH-0.2,
      fill:{ color:row.color }, line:{ color:row.color, width:1 }, rectRadius:0.1,
    });
    s.addText(row.intensity, {
      x:0.25, y:rowY+0.1, w:1.4, h:rowH-0.2,
      fontSize:11, color:row.textColor, bold:true, align:"center", valign:"middle",
    });

    // Reduction
    s.addText(row.reduction, {
      x:1.85, y:rowY, w:1.65, h:rowH,
      fontSize:12, color:row.color, bold:true, align:"center", valign:"middle",
    });

    // Drugs list
    const drugText = row.drugs.map(d => `${d.drug}  ${d.doses}`).join("\n");
    s.addText(drugText, {
      x:3.65, y:rowY+0.08, w:2.9, h:rowH-0.16,
      fontSize:8.5, color:C.darkGrey, align:"left", valign:"top", margin:4, wrap:true,
    });

    // Doses merged into drug text above
    // Use When
    s.addText(row.uses, {
      x:8.95, y:rowY+0.08, w:4.1, h:rowH-0.16,
      fontSize:8.5, color:C.darkGrey, align:"left", valign:"top", margin:4, wrap:true,
    });

    rowY += rowH + 0.06;
  });

  // Add-on therapy note
  s.addShape(pres.ShapeType.roundRect, {
    x:0.2, y:6.2, w:12.9, h:0.7,
    fill:{ color:"EAF4FF" }, line:{ color:C.sky, width:1.5 }, rectRadius:0.1,
  });
  s.addText([
    { text:"Add-On Therapy if LDL-C target not met on maximum tolerated statin:  ", options:{ bold:true, fontSize:9.5, color:C.navy } },
    { text:"Step 1 → Ezetimibe 10 mg OD  |  Step 2 → PCSK9 Inhibitor (evolocumab / alirocumab) — especially for very high-risk ASCVD or FH", options:{ bold:false, fontSize:9.5, color:C.darkGrey } },
  ], { x:0.3, y:6.22, w:12.7, h:0.65, valign:"middle", margin:5 });

  // Footer
  s.addShape(pres.ShapeType.rect, { x:0, y:7.22, w:13.3, h:0.28, fill:{ color:C.navy } });
  s.addText("2026 ACC/AHA Dyslipidemia Guideline  |  Harrison's 22E  |  For OPD Use", {
    x:0, y:7.22, w:13.3, h:0.28, fontSize:7.5, color:C.grey, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – SPECIAL POPULATIONS + MONITORING
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();

  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:7.5, fill:{ color:C.offWhite } });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:13.3, h:0.55, fill:{ color:C.navy } });
  s.addText("SPECIAL POPULATIONS  &  MONITORING", {
    x:0, y:0, w:13.3, h:0.55,
    fontSize:14, color:C.white, bold:true, align:"center", valign:"middle", charSpacing:2,
  });

  // Left panel: Special Populations
  s.addShape(pres.ShapeType.roundRect, {
    x:0.2, y:0.65, w:6.1, h:6.5,
    fill:{ color:C.white }, line:{ color:C.sky, width:1.5 }, rectRadius:0.1,
  });
  s.addShape(pres.ShapeType.rect, { x:0.2, y:0.65, w:6.1, h:0.42, fill:{ color:C.teal } });
  // Round top corners of header
  s.addText("SPECIAL POPULATIONS", {
    x:0.2, y:0.65, w:6.1, h:0.42,
    fontSize:11, color:C.white, bold:true, align:"center", valign:"middle",
  });

  const populations = [
    { title:"Pregnancy", color:C.red, text:"ABSOLUTELY CONTRAINDICATED\nStop before conception or as soon as detected\n(teratogenic — Category X)" },
    { title:"CKD (non-dialysis)", color:C.teal, text:"Moderate intensity preferred\nRosuvastatin — caution at high doses (renal excretion)\nPravastatin / Fluvastatin — safer options" },
    { title:"Elderly (> 75 yrs)", color:C.amber, text:"Individualize: clear benefit in 2° prevention\nPrimary prevention — shared decision making\nStart low, titrate slowly; monitor CK / LFT" },
    { title:"HIV Patients", color:C.teal, text:"Moderate-to-high intensity statin recommended\nAvoid simvastatin/lovastatin with PIs (high interaction)\nPravastatin or rosuvastatin preferred" },
    { title:"Liver Disease", color:C.red, text:"Active liver disease = CONTRAINDICATED\nMild-moderate hepatic impairment: use with caution\nMonitor LFTs; avoid high-dose statins" },
    { title:"Drug Interactions", color:C.amber, text:"Macrolides, azole antifungals, cyclosporine, gemfibrozil\n→ Avoid co-administration (↑ myopathy risk)\nPravastatin / rosuvastatin lowest interaction" },
  ];

  let py = 1.18;
  populations.forEach(p => {
    s.addShape(pres.ShapeType.roundRect, {
      x:0.35, y:py, w:5.8, h:0.72,
      fill:{ color:C.offWhite }, line:{ color:p.color, width:1.5 }, rectRadius:0.07,
    });
    s.addShape(pres.ShapeType.roundRect, {
      x:0.35, y:py, w:1.35, h:0.72,
      fill:{ color:p.color }, line:{ color:p.color, width:0 }, rectRadius:0.07,
    });
    s.addText(p.title, {
      x:0.35, y:py, w:1.35, h:0.72,
      fontSize:8, color:C.white, bold:true, align:"center", valign:"middle",
    });
    s.addText(p.text, {
      x:1.75, y:py+0.04, w:4.3, h:0.65,
      fontSize:7.5, color:C.darkGrey, align:"left", valign:"top", margin:3, wrap:true,
    });
    py += 0.82;
  });

  // Right panel: Monitoring
  s.addShape(pres.ShapeType.roundRect, {
    x:6.65, y:0.65, w:6.45, h:6.5,
    fill:{ color:C.white }, line:{ color:C.teal, width:1.5 }, rectRadius:0.1,
  });
  s.addShape(pres.ShapeType.rect, { x:6.65, y:0.65, w:6.45, h:0.42, fill:{ color:C.teal } });
  s.addText("MONITORING & FOLLOW-UP", {
    x:6.65, y:0.65, w:6.45, h:0.42,
    fontSize:11, color:C.white, bold:true, align:"center", valign:"middle",
  });

  const monitorItems = [
    {
      icon:"🔬", title:"Baseline Workup (BEFORE starting)",
      steps:["Fasting lipid panel (LDL-C, HDL, TG)", "ALT / AST (baseline LFT)", "Fasting glucose or HbA1c", "CK (if high myopathy risk: elderly, renal, multiple drugs)", "Calculate PREVENT-ASCVD risk score (primary prevention)"],
      color:C.navy,
    },
    {
      icon:"📅", title:"Follow-Up Lipid Panel",
      steps:["4–12 weeks after initiating or changing dose", "Goal: ≥50% reduction (high-intensity) / 30–49% (moderate)", "Annual check thereafter if on target"],
      color:C.teal,
    },
    {
      icon:"💊", title:"Statin Side Effects — When to Act",
      steps:["Myalgia (3-5%): Check CK. Mild → continue; CK >10× ULN → STOP", "Transaminase rise: usually mild/transient; stop if >3× ULN persistent", "New DM: counsel patient — CV benefit outweighs risk", "Routine CK monitoring NOT needed without symptoms"],
      color:C.amber,
    },
    {
      icon:"🔄", title:"If Target NOT Met",
      steps:["Maximise statin dose first", "Add Ezetimibe 10 mg OD (+ ~18% LDL-C reduction)", "Add PCSK9i (evolocumab / alirocumab) for very high risk / FH"],
      color:C.red,
    },
  ];

  let my = 1.18;
  monitorItems.forEach(m => {
    const itemH = m.steps.length * 0.22 + 0.38;
    s.addShape(pres.ShapeType.roundRect, {
      x:6.8, y:my, w:6.15, h:itemH,
      fill:{ color:C.offWhite }, line:{ color:m.color, width:1.5 }, rectRadius:0.07,
    });
    s.addText(m.title, {
      x:6.85, y:my+0.04, w:6.05, h:0.26,
      fontSize:9, color:m.color, bold:true, align:"left", valign:"middle", margin:2,
    });
    m.steps.forEach((step, si) => {
      s.addText("• " + step, {
        x:6.9, y:my+0.3+si*0.21, w:6.0, h:0.21,
        fontSize:7.8, color:C.darkGrey, align:"left", valign:"middle", margin:2, wrap:true,
      });
    });
    my += itemH + 0.1;
  });

  // Footer
  s.addShape(pres.ShapeType.rect, { x:0, y:7.22, w:13.3, h:0.28, fill:{ color:C.navy } });
  s.addText("2026 ACC/AHA Dyslipidemia Guideline  |  Harrison's 22E  |  For OPD Use", {
    x:0, y:7.22, w:13.3, h:0.28, fontSize:7.5, color:C.grey, align:"center", valign:"middle",
  });
}

// ════════════════════════════════════════════════════════════════════════════
// WRITE FILE
// ════════════════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/statin-flowchart/Statin_Decision_Flowchart.pptx" })
  .then(() => console.log("SUCCESS: File written."))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

Running Command

cd /home/daytona/workspace/statin-flowchart && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/statin-flowchart/

Your statin flowchart presentation is ready (164 KB):

Statin Decision Flowchart

Presentation · PPTX

Here is what is included across the 4 slides:

Slide 1 - Cover Dark navy/teal professional design with title, subtitle, and topic badges.

Slide 2 - Main Decision Flowchart A colour-coded step-by-step decision tree flowing from "New OPD Patient" through:

Established ASCVD? → High-intensity statin (red box, secondary prevention)
LDL-C ≥190 mg/dL? → High-intensity statin (FH / severe)
Diabetes age 40-75? → Moderate-intensity statin
Calculate 10-year PREVENT-ASCVD risk → three branches:
- <3% → Lifestyle modification only (green)
- 3-<10% → Check risk enhancers + shared decision making (amber), with CAC scoring guide
- ≥10% → High/mod-high intensity statin (red)

Slide 3 - Statin Intensity Table Colour-banded table with HIGH / MODERATE / LOW intensity rows showing:

LDL-C reduction %, drug names, doses, and clinical indications
Add-on therapy strip (ezetimibe → PCSK9i) at the bottom

Slide 4 - Special Populations & Monitoring Side-by-side panels covering:

Pregnancy, CKD, elderly, HIV, liver disease, drug interactions
Baseline workup, follow-up lipid panel timing, side effect management, and escalation ladder

Generate a quick-reference pocket card PDF from this flowchart

Reading File

Writing File

~/statin-flowchart/pocket_card.py

"""
Statin Selection Quick-Reference Pocket Card
Size: 3.5 x 8.5 inches (tall card, 2 pages = front/back)
"""
from reportlab.lib.pagesizes import inch
from reportlab.lib import colors
from reportlab.lib.colors import HexColor
from reportlab.platypus import SimpleDocTemplate
from reportlab.pdfgen import canvas
from reportlab.lib.utils import simpleSplit
import math

# ── Page size ─────────────────────────────────────────────────────────────────
W, H = 3.5 * inch, 8.5 * inch

# ── Palette ───────────────────────────────────────────────────────────────────
NAVY    = HexColor("#0B2545")
TEAL    = HexColor("#1B6CA8")
SKY     = HexColor("#4DA6D9")
GREEN   = HexColor("#2E8B57")
AMBER   = HexColor("#D4870A")
RED     = HexColor("#C0392B")
YELLOW  = HexColor("#FFF3CD")
OFFWHITE= HexColor("#F4F8FC")
WHITE   = colors.white
DGREY   = HexColor("#2C3E50")
LGREY   = HexColor("#ECF0F1")
MGREY   = HexColor("#7F8C8D")

OUTPUT = "/home/daytona/workspace/statin-flowchart/Statin_Pocket_Card.pdf"

# ── Canvas helpers ─────────────────────────────────────────────────────────────
def rounded_rect(c, x, y, w, h, r=4, fill=None, stroke=None, stroke_w=0.75):
    c.saveState()
    if fill:
        c.setFillColor(fill)
    if stroke:
        c.setStrokeColor(stroke)
        c.setLineWidth(stroke_w)
    else:
        c.setLineWidth(0)
    c.roundRect(x, y, w, h, r, fill=1 if fill else 0, stroke=1 if stroke else 0)
    c.restoreState()

def rect(c, x, y, w, h, fill=None, stroke=None, stroke_w=0.5):
    c.saveState()
    if fill:  c.setFillColor(fill)
    if stroke: c.setStrokeColor(stroke); c.setLineWidth(stroke_w)
    c.rect(x, y, w, h, fill=1 if fill else 0, stroke=1 if stroke else 0)
    c.restoreState()

def text(c, txt, x, y, size=7, color=DGREY, bold=False, align="left", max_w=None):
    c.saveState()
    c.setFillColor(color)
    face = "Helvetica-Bold" if bold else "Helvetica"
    c.setFont(face, size)
    if align == "center" and max_w:
        c.drawCentredString(x + max_w / 2, y, txt)
    elif align == "right" and max_w:
        c.drawRightString(x + max_w, y, txt)
    else:
        c.drawString(x, y, txt)
    c.restoreState()

def multiline(c, txt, x, y, size=6.5, color=DGREY, bold=False, max_w=None, line_h=9):
    """Wrap and draw multi-line text. Returns final y."""
    face = "Helvetica-Bold" if bold else "Helvetica"
    mw = max_w or (W - x - 6)
    lines = simpleSplit(txt, face, size, mw)
    cy = y
    c.saveState()
    c.setFillColor(color)
    c.setFont(face, size)
    for line in lines:
        c.drawString(x, cy, line)
        cy -= line_h
    c.restoreState()
    return cy

def section_header(c, title, y, bg=NAVY, text_color=WHITE, h=13):
    rect(c, 4, y, W-8, h, fill=bg)
    text(c, title, 4, y + 3.5, size=7, color=text_color, bold=True, align="center", max_w=W-8)
    return y - h - 2

def arrow_down(c, x, y, length=8):
    c.saveState()
    c.setStrokeColor(NAVY)
    c.setLineWidth(0.8)
    c.line(x, y, x, y - length)
    # arrowhead
    c.setFillColor(NAVY)
    p = c.beginPath()
    p.moveTo(x - 3, y - length + 3)
    p.lineTo(x, y - length)
    p.lineTo(x + 3, y - length + 3)
    p.close()
    c.drawPath(p, fill=1, stroke=0)
    c.restoreState()

def diamond_node(c, cx, cy, hw, hh, fill=AMBER, stroke=NAVY, label="", label_size=6.5):
    """Draw diamond centred at (cx, cy)."""
    c.saveState()
    c.setFillColor(fill)
    c.setStrokeColor(stroke)
    c.setLineWidth(0.8)
    p = c.beginPath()
    p.moveTo(cx, cy + hh)      # top
    p.lineTo(cx + hw, cy)      # right
    p.lineTo(cx, cy - hh)      # bottom
    p.lineTo(cx - hw, cy)      # left
    p.close()
    c.drawPath(p, fill=1, stroke=1)
    c.restoreState()
    # label
    lines = simpleSplit(label, "Helvetica-Bold", label_size, hw * 1.8)
    total = len(lines) * (label_size + 1)
    sy = cy + total / 2 - label_size + 1
    c.saveState()
    c.setFillColor(NAVY)
    c.setFont("Helvetica-Bold", label_size)
    for ln in lines:
        c.drawCentredString(cx, sy, ln)
        sy -= label_size + 1
    c.restoreState()

def outcome_box(c, x, y, w, h, bg, title, sub, r=5):
    rounded_rect(c, x, y, w, h, r=r, fill=bg)
    # title
    c.saveState()
    c.setFillColor(WHITE)
    c.setFont("Helvetica-Bold", 6.5)
    c.drawCentredString(x + w/2, y + h - 10, title)
    c.setFont("Helvetica", 5.8)
    c.setFillColor(HexColor("#EEEEEE"))
    lines = simpleSplit(sub, "Helvetica", 5.8, w - 6)
    ty = y + h - 20
    for ln in lines:
        c.drawCentredString(x + w/2, ty, ln)
        ty -= 8
    c.restoreState()

# ══════════════════════════════════════════════════════════════════════════════
# PAGE 1 — FRONT (Decision Flowchart)
# ══════════════════════════════════════════════════════════════════════════════
def draw_front(c):
    margin = 6
    cw = W - 2 * margin  # content width

    # Background
    rect(c, 0, 0, W, H, fill=OFFWHITE)

    # Header
    rect(c, 0, H - 38, W, 38, fill=NAVY)
    c.saveState()
    c.setFillColor(SKY)
    c.setFont("Helvetica-Bold", 9.5)
    c.drawCentredString(W/2, H - 15, "STATIN SELECTION")
    c.setFont("Helvetica", 7)
    c.setFillColor(WHITE)
    c.drawCentredString(W/2, H - 26, "Quick-Reference Pocket Card")
    c.setFont("Helvetica", 5.5)
    c.setFillColor(MGREY)
    c.drawCentredString(W/2, H - 35, "2026 ACC/AHA Guideline  |  Harrison's 22E")
    c.restoreState()

    # Accent bar
    rect(c, 0, H - 40, W, 2, fill=TEAL)

    cy = H - 50  # current y (top of content)

    # START pill
    rounded_rect(c, margin+20, cy-14, cw-40, 14, r=7, fill=NAVY)
    text(c, "NEW OPD PATIENT", margin+20, cy-10, size=6.5, color=WHITE, bold=True,
         align="center", max_w=cw-40)
    cy -= 16

    # Arrow down
    arrow_down(c, W/2, cy, 8)
    cy -= 11

    # ── Decision 1: Established ASCVD? ──────────────────────────────────────
    diam_cx = W/2
    diam_hw = 58
    diam_hh = 17
    dcy = cy - diam_hh
    diamond_node(c, diam_cx, dcy, diam_hw, diam_hh, fill=HexColor("#FEF3C7"), stroke=AMBER,
                 label="Established ASCVD?", label_size=6.5)

    # YES → left
    c.saveState()
    c.setStrokeColor(GREEN); c.setLineWidth(0.8)
    c.line(diam_cx - diam_hw, dcy, margin, dcy)
    # arrowhead left
    c.setFillColor(GREEN)
    p = c.beginPath()
    p.moveTo(margin+4, dcy+3); p.lineTo(margin, dcy); p.lineTo(margin+4, dcy-3); p.close()
    c.drawPath(p, fill=1, stroke=0)
    c.restoreState()
    text(c, "YES", margin+1, dcy+2.5, size=5.5, color=GREEN, bold=True)

    # NO → down
    c.saveState(); c.setStrokeColor(NAVY); c.setLineWidth(0.8)
    c.line(diam_cx, dcy-diam_hh, diam_cx, dcy-diam_hh-7)
    c.restoreState()
    text(c, "NO", W/2+1, dcy-diam_hh-2, size=5.5, color=RED, bold=True)

    # LEFT BOX: 2° Prevention
    bh = 30
    outcome_box(c, margin, dcy-bh+8, 45, bh, bg=RED,
                title="HIGH INTENSITY",
                sub="2° Prevention\nTarget LDL<70")

    cy = dcy - diam_hh - 10

    # ── Decision 2: LDL-C ≥190? ─────────────────────────────────────────────
    dcy2 = cy - diam_hh
    diamond_node(c, diam_cx, dcy2, diam_hw, diam_hh, fill=HexColor("#FEF3C7"), stroke=AMBER,
                 label="LDL-C ≥190 mg/dL?", label_size=6.5)

    # YES → right
    c.saveState()
    c.setStrokeColor(RED); c.setLineWidth(0.8)
    c.line(diam_cx + diam_hw, dcy2, W-margin, dcy2)
    c.setFillColor(RED)
    p = c.beginPath()
    p.moveTo(W-margin-4, dcy2+3); p.lineTo(W-margin, dcy2); p.lineTo(W-margin-4, dcy2-3); p.close()
    c.drawPath(p, fill=1, stroke=0)
    c.restoreState()
    text(c, "YES", W-margin-20, dcy2+2.5, size=5.5, color=GREEN, bold=True)

    # NO → down
    c.saveState(); c.setStrokeColor(NAVY); c.setLineWidth(0.8)
    c.line(diam_cx, dcy2-diam_hh, diam_cx, dcy2-diam_hh-7)
    c.restoreState()
    text(c, "NO", W/2+1, dcy2-diam_hh-2, size=5.5, color=RED, bold=True)

    # RIGHT BOX: FH
    outcome_box(c, W-margin-45, dcy2-22+8, 45, 30, bg=RED,
                title="HIGH INTENSITY",
                sub="FH/Severe\nAdd ezetimibe")

    cy = dcy2 - diam_hh - 10

    # ── Decision 3: Diabetes 40-75y? ────────────────────────────────────────
    dcy3 = cy - diam_hh
    diamond_node(c, diam_cx, dcy3, diam_hw, diam_hh, fill=HexColor("#FEF3C7"), stroke=AMBER,
                 label="DM age 40-75 yrs?", label_size=6.5)

    # YES → left
    c.saveState()
    c.setStrokeColor(GREEN); c.setLineWidth(0.8)
    c.line(diam_cx - diam_hw, dcy3, margin, dcy3)
    c.setFillColor(GREEN)
    p = c.beginPath()
    p.moveTo(margin+4, dcy3+3); p.lineTo(margin, dcy3); p.lineTo(margin+4, dcy3-3); p.close()
    c.drawPath(p, fill=1, stroke=0)
    c.restoreState()
    text(c, "YES", margin+1, dcy3+2.5, size=5.5, color=GREEN, bold=True)

    # NO → down
    c.saveState(); c.setStrokeColor(NAVY); c.setLineWidth(0.8)
    c.line(diam_cx, dcy3-diam_hh, diam_cx, dcy3-diam_hh-7)
    c.restoreState()
    text(c, "NO", W/2+1, dcy3-diam_hh-2, size=5.5, color=RED, bold=True)

    # LEFT BOX: DM
    outcome_box(c, margin, dcy3-22+8, 45, 30, bg=TEAL,
                title="MOD INTENSITY",
                sub="Diabetes\n↑ if risk ≥10%")

    cy = dcy3 - diam_hh - 10

    # ── PREVENT Risk score box ───────────────────────────────────────────────
    rounded_rect(c, margin, cy-22, cw, 22, r=5, fill=NAVY)
    text(c, "Calculate PREVENT-ASCVD 10-yr Risk", margin, cy-11,
         size=6.5, color=WHITE, bold=True, align="center", max_w=cw)
    text(c, "(Age 30-79, no known ASCVD, LDL 70-189)", margin, cy-20,
         size=5.8, color=SKY, bold=False, align="center", max_w=cw)

    arrow_down(c, W/2, cy-23, 8)
    cy -= 34

    # ── Three risk branches ──────────────────────────────────────────────────
    branch_y = cy - 2
    bw = (cw - 6) / 3
    bh2 = 40

    # Draw horizontal line
    c.saveState(); c.setStrokeColor(NAVY); c.setLineWidth(0.7)
    c.line(margin + bw/2, branch_y, W - margin - bw/2, branch_y)
    # Left branch arrow
    c.line(margin + bw/2, branch_y, margin + bw/2, branch_y - 8)
    # Mid branch arrow (already had vertical)
    c.line(W/2, branch_y, W/2, branch_y - 8)
    # Right branch arrow
    c.line(W - margin - bw/2, branch_y, W - margin - bw/2, branch_y - 8)
    c.restoreState()

    # LEFT: <3%
    rounded_rect(c, margin, branch_y - 8 - bh2, bw, bh2, r=4, fill=GREEN)
    c.saveState()
    c.setFillColor(WHITE); c.setFont("Helvetica-Bold", 6.5)
    c.drawCentredString(margin + bw/2, branch_y - 18, "< 3%")
    c.setFont("Helvetica", 5.5); c.setFillColor(HexColor("#CCFFCC"))
    c.drawCentredString(margin + bw/2, branch_y - 27, "Lifestyle")
    c.drawCentredString(margin + bw/2, branch_y - 35, "Only")
    c.drawCentredString(margin + bw/2, branch_y - 43, "No statin")
    c.restoreState()

    # MID: 3-<10%
    rounded_rect(c, margin + bw + 3, branch_y - 8 - bh2, bw, bh2, r=4, fill=AMBER)
    c.saveState()
    c.setFillColor(WHITE); c.setFont("Helvetica-Bold", 6.5)
    c.drawCentredString(margin + bw + 3 + bw/2, branch_y - 18, "3-<10%")
    c.setFont("Helvetica", 5.5); c.setFillColor(YELLOW)
    c.drawCentredString(margin + bw + 3 + bw/2, branch_y - 27, "Shared")
    c.drawCentredString(margin + bw + 3 + bw/2, branch_y - 35, "Decision")
    c.drawCentredString(margin + bw + 3 + bw/2, branch_y - 43, "MOD statin")
    c.restoreState()

    # RIGHT: ≥10%
    rounded_rect(c, W - margin - bw, branch_y - 8 - bh2, bw, bh2, r=4, fill=RED)
    c.saveState()
    c.setFillColor(WHITE); c.setFont("Helvetica-Bold", 6.5)
    c.drawCentredString(W - margin - bw/2, branch_y - 18, "≥ 10%")
    c.setFont("Helvetica", 5.5); c.setFillColor(HexColor("#FFCCCC"))
    c.drawCentredString(W - margin - bw/2, branch_y - 27, "HIGH")
    c.drawCentredString(W - margin - bw/2, branch_y - 35, "intensity")
    c.drawCentredString(W - margin - bw/2, branch_y - 43, "statin")
    c.restoreState()

    cy = branch_y - 8 - bh2 - 5

    # ── Risk Enhancers strip ────────────────────────────────────────────────
    eh = 42
    rounded_rect(c, margin, cy-eh, cw, eh, r=4, fill=HexColor("#FFF8E1"), stroke=AMBER, stroke_w=0.8)
    text(c, "RISK ENHANCERS (push 3-<10% toward statin):", margin+3, cy-9,
         size=6, color=AMBER, bold=True)
    enhancers = [
        "Fam hx premature ASCVD  •  LDL ≥160  •  hs-CRP ≥2",
        "Lp(a) ≥50  •  ApoB ≥130  •  CKD  •  Metabolic Synd.",
        "RA / Psoriasis / HIV  •  Pre-eclampsia / Early menopause",
        "CAC=0 → withhold  |  CAC ≥100 → initiate statin",
    ]
    ey2 = cy - 18
    for line in enhancers:
        text(c, line, margin+3, ey2, size=5.8, color=DGREY)
        ey2 -= 8.5

    cy -= eh + 4

    # ── Footer ──────────────────────────────────────────────────────────────
    rect(c, 0, 0, W, 16, fill=NAVY)
    text(c, "See reverse for: Statin Doses  |  Monitoring  |  Special Populations",
         margin, 10, size=5.5, color=SKY, bold=False, align="center", max_w=cw)
    text(c, "ACC/AHA 2026  |  Harrison's 22E",
         margin, 3, size=5, color=MGREY, align="center", max_w=cw)


# ══════════════════════════════════════════════════════════════════════════════
# PAGE 2 — BACK (Statin doses + Monitoring + Special populations)
# ══════════════════════════════════════════════════════════════════════════════
def draw_back(c):
    margin = 6
    cw = W - 2 * margin

    rect(c, 0, 0, W, H, fill=OFFWHITE)

    # Header
    rect(c, 0, H - 28, W, 28, fill=TEAL)
    text(c, "STATIN DOSES & MONITORING", margin, H-11, size=8,
         color=WHITE, bold=True, align="center", max_w=cw)
    text(c, "Pocket Reference  —  Back", margin, H-22, size=6,
         color=HexColor("#CCE5FF"), align="center", max_w=cw)
    rect(c, 0, H-30, W, 2, fill=SKY)

    cy = H - 38

    # ── Intensity table header ───────────────────────────────────────────────
    rect(c, margin, cy-11, cw, 11, fill=NAVY)
    cols = [6, 52, 110, 165]  # x positions
    hdrs = ["LEVEL", "DRUG", "DOSE (mg)", "LDL↓"]
    for i, h in enumerate(hdrs):
        text(c, h, cols[i]+margin, cy-8, size=5.8, color=WHITE, bold=True)
    cy -= 11

    # Table data
    rows = [
        # (level, color, drug, dose, reduction)
        ("HIGH",   RED,   "Atorvastatin",  "40, 80",    "≥50%"),
        ("HIGH",   RED,   "Rosuvastatin",  "20, 40",    "≥50%"),
        ("MOD",    AMBER, "Atorvastatin",  "10, 20",    "30-49%"),
        ("MOD",    AMBER, "Rosuvastatin",  "5, 10",     "30-49%"),
        ("MOD",    AMBER, "Simvastatin",   "20, 40",    "30-49%"),
        ("MOD",    AMBER, "Pravastatin",   "40, 80",    "30-49%"),
        ("MOD",    AMBER, "Pitavastatin",  "2, 4",      "30-49%"),
        ("LOW",    GREEN, "Simvastatin",   "10",        "<30%"),
        ("LOW",    GREEN, "Pravastatin",   "10, 20",    "<30%"),
        ("LOW",    GREEN, "Fluvastatin",   "20-40",     "<30%"),
    ]
    for i, (lvl, col, drug, dose, red) in enumerate(rows):
        row_bg = WHITE if i % 2 == 0 else HexColor("#EDF3FA")
        rect(c, margin, cy-10, cw, 10, fill=row_bg)
        # Level badge
        rounded_rect(c, margin+1, cy-9, 46, 8.5, r=2, fill=col)
        c.saveState()
        c.setFillColor(WHITE); c.setFont("Helvetica-Bold", 5.5)
        c.drawCentredString(margin+24, cy-3.5, lvl)
        c.restoreState()
        text(c, drug, cols[1]+margin, cy-7.5, size=6, color=DGREY)
        text(c, dose, cols[2]+margin, cy-7.5, size=6, color=DGREY)
        text(c, red,  cols[3]+margin, cy-7.5, size=6, color=col, bold=True)
        cy -= 10

    # Divider
    rect(c, margin, cy-1, cw, 1, fill=TEAL)
    cy -= 4

    # ── Add-on therapy ────────────────────────────────────────────────────────
    rounded_rect(c, margin, cy-22, cw, 22, r=4, fill=HexColor("#EAF4FF"), stroke=SKY, stroke_w=0.8)
    text(c, "ADD-ON THERAPY (if LDL target not met):", margin+3, cy-9,
         size=6.5, color=TEAL, bold=True)
    text(c, "Step 1: Ezetimibe 10 mg OD  (+18% LDL reduction)", margin+3, cy-17.5,
         size=6, color=DGREY)
    text(c, "Step 2: PCSK9 inhibitor (evolocumab / alirocumab)", margin+3, cy-25,
         size=6, color=DGREY)
    cy -= 26

    # ── Monitoring ────────────────────────────────────────────────────────────
    rect(c, margin, cy-11, cw, 11, fill=NAVY)
    text(c, "MONITORING", margin, cy-8, size=7, color=WHITE, bold=True,
         align="center", max_w=cw)
    cy -= 11

    monitor_items = [
        ("Before starting:", "Lipid panel, ALT/AST, Fasting glucose, CK (if high risk)", TEAL),
        ("4-12 wks after:", "Repeat fasting lipid panel; check % LDL-C reduction", TEAL),
        ("Myalgia (3-5%):", "Check CK. CK >10× ULN → STOP statin", AMBER),
        ("Transaminase ↑:", "Usually mild/transient. Stop if >3× ULN persistent", AMBER),
        ("New DM risk:", "Counsel: CV benefit far outweighs DM risk", GREEN),
        ("Routine CK:", "NOT needed unless symptoms arise", GREEN),
    ]
    for (label_t, detail, col) in monitor_items:
        bg = WHITE
        rect(c, margin, cy-16, cw, 16, fill=bg, stroke=LGREY, stroke_w=0.3)
        rounded_rect(c, margin+1, cy-15, 52, 13, r=2, fill=col)
        c.saveState()
        c.setFillColor(WHITE); c.setFont("Helvetica-Bold", 5.5)
        lines = simpleSplit(label_t, "Helvetica-Bold", 5.5, 50)
        ly = cy - 8
        for l in lines:
            c.drawCentredString(margin+27, ly, l)
            ly -= 7
        c.restoreState()
        multiline(c, detail, margin+56, cy-8, size=5.8, color=DGREY,
                  max_w=cw-50, line_h=7.5)
        cy -= 16

    # ── Special Populations ─────────────────────────────────────────────────
    rect(c, margin, cy-11, cw, 11, fill=NAVY)
    text(c, "SPECIAL POPULATIONS", margin, cy-8, size=7, color=WHITE, bold=True,
         align="center", max_w=cw)
    cy -= 11

    sp_items = [
        ("PREGNANCY",         "CONTRAINDICATED — stop immediately", RED),
        ("CKD",               "Moderate intensity preferred; pravastatin/fluvastatin safer", TEAL),
        ("ELDERLY >75y",      "2° prevention: continue; 1° prevention: individualize", AMBER),
        ("HIV",               "Avoid simvastatin with PIs; use pravastatin/rosuvastatin", TEAL),
        ("LIVER DISEASE",     "Active disease = CONTRAINDICATED; caution in mild/mod", RED),
        ("DRUG INTERACTIONS", "Macrolides, azoles, gemfibrozil ↑ myopathy risk", AMBER),
    ]
    for (sp_label, detail, col) in sp_items:
        rect(c, margin, cy-14, cw, 14, fill=WHITE, stroke=LGREY, stroke_w=0.3)
        rounded_rect(c, margin+1, cy-13, 52, 12, r=2, fill=col)
        c.saveState()
        c.setFillColor(WHITE); c.setFont("Helvetica-Bold", 5)
        lines = simpleSplit(sp_label, "Helvetica-Bold", 5, 50)
        ly = cy - 7
        for l in lines:
            c.drawCentredString(margin+27, ly, l)
            ly -= 6
        c.restoreState()
        multiline(c, detail, margin+56, cy-7, size=5.5, color=DGREY,
                  max_w=cw-52, line_h=7)
        cy -= 14

    # ── LDL targets quick ref ────────────────────────────────────────────────
    th = 28
    rounded_rect(c, margin, cy-th, cw, th, r=4, fill=NAVY, stroke=SKY, stroke_w=0.8)
    text(c, "LDL-C TARGETS", margin, cy-9, size=6.5, color=SKY, bold=True,
         align="center", max_w=cw)
    targets = [
        "2° Prevention (very high risk): < 55 mg/dL  (≥50% reduction)",
        "2° Prevention:  < 70 mg/dL  (≥50% reduction)",
        "1° Prevention (high risk):  < 100 mg/dL",
        "1° Prevention (mod risk):   LDL reduction 30-49%",
    ]
    ty2 = cy - 18
    for t in targets:
        text(c, t, margin+3, ty2, size=5.5, color=WHITE)
        ty2 -= 7.5
    cy -= th + 3

    # Footer
    rect(c, 0, 0, W, 14, fill=TEAL)
    text(c, "2026 ACC/AHA Dyslipidemia Guideline  |  Harrison's 22E (2025)",
         margin, 9, size=5.5, color=WHITE, align="center", max_w=cw)
    text(c, "For educational use in outpatient clinical practice",
         margin, 2, size=5, color=HexColor("#CCE5FF"), align="center", max_w=cw)


# ══════════════════════════════════════════════════════════════════════════════
# RENDER
# ══════════════════════════════════════════════════════════════════════════════
c = canvas.Canvas(OUTPUT, pagesize=(W, H))
c.setTitle("Statin Selection — Quick Reference Pocket Card")
c.setAuthor("Orris Clinical Tools")
c.setSubject("Statin initiation guidelines 2026")

draw_front(c)
c.showPage()
draw_back(c)
c.showPage()
c.save()
print("SUCCESS:", OUTPUT)

Running Command

cd /home/daytona/workspace/statin-flowchart && python pocket_card.py 2>&1

Running Command

ls -lh /home/daytona/workspace/statin-flowchart/Statin_Pocket_Card.pdf

Your pocket card is ready:

Statin Pocket Card

PDF Document · PDF

Format: 3.5 × 8.5 inches (standard tall wallet/pocket card), 2 pages — print double-sided and fold.

Page 1 - FRONT (Decision Flowchart)

Start node → 4 sequential diamond decision nodes
Branch 1: Established ASCVD? → High-intensity statin (red)
Branch 2: LDL-C ≥190? → High-intensity statin / FH (red, right)
Branch 3: DM age 40-75? → Moderate-intensity statin (teal, left)
Branch 4: PREVENT-ASCVD 10-yr risk → 3-column split: <3% (green/lifestyle), 3-<10% (amber/discuss), ≥10% (red/high statin)
Risk enhancer strip at bottom (Lp(a), hs-CRP, CAC, CKD, etc.)

Page 2 - BACK (Reference tables)

Statin intensity table: HIGH / MOD / LOW with all drug names and doses
Add-on therapy ladder: ezetimibe → PCSK9 inhibitor
Monitoring section: before starting, 4-12 week follow-up, myalgia/transaminase rules
Special populations: pregnancy, CKD, elderly, HIV, liver disease, drug interactions
LDL-C targets quick reference box

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