const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "General Medicine Residency";
pres.title = "Pulmonary Hypertension, Venous Thromboembolism & Pulmonary Embolism";

// ─── COLOR PALETTE ──────────────────────────────────────────────────────────
const C = {
  navy:      "0D2B55",   // dominant dark bg
  teal:      "1A7A8A",   // section accents
  tealLight: "2BA9BD",   // subheadings / icons
  gold:      "E8A838",   // highlight / key facts
  cream:     "F5F0E8",   // body text / light text
  white:     "FFFFFF",
  red:       "C0392B",   // danger / alert
  orange:    "E67E22",   // warning
  green:     "1E8449",   // favorable
  lightBg:   "EBF4F7",   // light slide bg
  darkText:  "1C2B3A",   // text on light bg
  midGray:   "7F8C9A",   // secondary text
};

// ─── HELPER FUNCTIONS ───────────────────────────────────────────────────────
function addHeaderBar(slide, title, subtitle = "") {
  // gradient-like top bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.15, fill: { color: C.navy } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 1.15, w: 10, h: 0.06, fill: { color: C.gold } });
  slide.addText(title, {
    x: 0.35, y: 0.08, w: 9.3, h: 0.7,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
    margin: 0,
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.35, y: 0.78, w: 9.3, h: 0.35,
      fontSize: 11, color: C.tealLight, fontFace: "Calibri", italic: true, margin: 0,
    });
  }
}

function addBullets(slide, items, x, y, w, h, opts = {}) {
  const textArr = items.map((item, i) => {
    const isSubBullet = item.startsWith("  ");
    return {
      text: item.replace(/^  /, ""),
      options: {
        bullet: isSubBullet ? { indent: 28 } : { indent: 14 },
        fontSize: isSubBullet ? (opts.fontSize ? opts.fontSize - 1 : 12) : (opts.fontSize || 13.5),
        color: isSubBullet ? C.midGray : (opts.color || C.darkText),
        bold: item.startsWith("★") ? true : false,
        breakLine: i < items.length - 1,
        paraSpaceAfter: isSubBullet ? 2 : 5,
      },
    };
  });
  slide.addText(textArr, { x, y, w, h, fontFace: "Calibri", valign: "top", ...opts });
}

function addSectionDivider(slide, sectionNum, title, subtitle = "") {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navy } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 2.55, w: 0.12, h: 0.6, fill: { color: C.gold } });
  slide.addShape(pres.ShapeType.rect, { x: 0.12, y: 2.7, w: 9.88, h: 0.05, fill: { color: C.teal } });
  slide.addText(`SECTION ${sectionNum}`, {
    x: 0.35, y: 1.5, w: 9.3, h: 0.45,
    fontSize: 12, bold: true, color: C.tealLight, charSpacing: 5, fontFace: "Calibri",
  });
  slide.addText(title, {
    x: 0.35, y: 1.95, w: 9.3, h: 0.85,
    fontSize: 30, bold: true, color: C.white, fontFace: "Calibri",
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.35, y: 2.82, w: 9.3, h: 0.6,
      fontSize: 14, color: C.cream, fontFace: "Calibri", italic: true,
    });
  }
}

// Fetch images
const imageUrls = [
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_ebf92b0046249005c8e997ff6039f9ec0d5521a4efb1430c222856b78526ff0f.jpg",   // PH vascular remodeling
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_36ba2b6e62b466ee682caa4c77dc1dc15490097fcd989ca04459142b52448274.jpg",   // PAH targeted therapy
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_85b18abfd88a4a587025db3f653326599ebe0b6ee2061cdef197b0f120e2868a.jpg",   // PE CTPA
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_ecd6adc87b0fe7ae39b5a313abc53095bd516a1d1ea3153794b93cbd508cb2aa.jpg",   // DVT ultrasound
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_f9ee0041089f9275c4754735c8d863ba30d460b294c49312cd8d48a1f408a76f.jpg",   // CTEPH pathophysiology
];

console.log("Fetching images...");
let imgs = [];
try {
  const result = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  );
  imgs = JSON.parse(result.toString());
  console.log("Images fetched:", imgs.map(i => i.error ? "ERROR: " + i.error : "OK").join(", "));
} catch (e) {
  console.error("Image fetch error:", e.message);
  imgs = imageUrls.map(() => ({ base64: null }));
}

// ============================================================================
//  SLIDE 1 — TITLE SLIDE
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 4.0, w: 10, h: 1.625, fill: { color: C.teal } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 3.92, w: 10, h: 0.1, fill: { color: C.gold } });

  s.addText("PULMONARY HYPERTENSION", {
    x: 0.5, y: 0.55, w: 9, h: 0.65,
    fontSize: 28, bold: true, color: C.white, fontFace: "Calibri", align: "center",
  });
  s.addText("Venous Thromboembolism & Pulmonary Embolism", {
    x: 0.5, y: 1.25, w: 9, h: 0.55,
    fontSize: 20, bold: false, color: C.gold, fontFace: "Calibri", align: "center",
  });
  s.addText("Updated with 2026 AHA/ACC Guidelines", {
    x: 0.5, y: 1.85, w: 9, h: 0.4,
    fontSize: 13, italic: true, color: C.tealLight, fontFace: "Calibri", align: "center",
  });

  // Decorative lines
  s.addShape(pres.ShapeType.rect, { x: 2.5, y: 2.4, w: 5, h: 0.04, fill: { color: C.gold } });

  s.addText("General Medicine Residency – Year 2", {
    x: 0.5, y: 4.1, w: 9, h: 0.38,
    fontSize: 13, color: C.white, fontFace: "Calibri", align: "center",
  });
  s.addText("May 2026", {
    x: 0.5, y: 4.5, w: 9, h: 0.35,
    fontSize: 12, color: C.cream, fontFace: "Calibri", align: "center",
  });

  // Sources badge
  s.addShape(pres.ShapeType.roundRect, { x: 3.2, y: 5.05, w: 3.6, h: 0.38, fill: { color: C.tealLight }, rectRadius: 0.05 });
  s.addText("Sources: Murray & Nadel · Fishman's · 2026 AHA/ACC", {
    x: 3.2, y: 5.05, w: 3.6, h: 0.38,
    fontSize: 8.5, color: C.white, fontFace: "Calibri", align: "center",
  });
}

// ============================================================================
//  SLIDE 2 — OUTLINE
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "Presentation Outline");

  const sections = [
    { num: "01", title: "Pulmonary Hypertension – Overview & Classification", col: 0 },
    { num: "02", title: "PH – Pathophysiology & Epidemiology", col: 0 },
    { num: "03", title: "PH – Diagnosis & Clinical Features", col: 0 },
    { num: "04", title: "PH – Management & Targeted Therapy", col: 0 },
    { num: "05", title: "Venous Thromboembolism – DVT", col: 1 },
    { num: "06", title: "Pulmonary Embolism – Pathophysiology & Risk", col: 1 },
    { num: "07", title: "PE – Diagnosis (2026 AHA/ACC Framework)", col: 1 },
    { num: "08", title: "PE – Management & Guidelines 2026", col: 1 },
    { num: "09", title: "CTEPH – Bridging PH and PE", col: 1 },
    { num: "10", title: "Follow-up, PERC, & Key Takeaways", col: 1 },
  ];

  const leftItems = sections.filter(x => x.col === 0);
  const rightItems = sections.filter(x => x.col === 1);

  leftItems.forEach((item, i) => {
    s.addShape(pres.ShapeType.roundRect, {
      x: 0.3, y: 1.38 + i * 0.73, w: 4.5, h: 0.62,
      fill: { color: C.navy }, rectRadius: 0.05,
    });
    s.addText(item.num, {
      x: 0.35, y: 1.42 + i * 0.73, w: 0.5, h: 0.52,
      fontSize: 14, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle",
    });
    s.addText(item.title, {
      x: 0.88, y: 1.42 + i * 0.73, w: 3.85, h: 0.52,
      fontSize: 10.5, color: C.white, fontFace: "Calibri", valign: "middle",
    });
  });

  rightItems.forEach((item, i) => {
    s.addShape(pres.ShapeType.roundRect, {
      x: 5.2, y: 1.38 + i * 0.42, w: 4.5, h: 0.36,
      fill: { color: i < 3 ? C.teal : C.navy }, rectRadius: 0.04,
    });
    s.addText(item.num, {
      x: 5.25, y: 1.4 + i * 0.42, w: 0.42, h: 0.3,
      fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle",
    });
    s.addText(item.title, {
      x: 5.7, y: 1.4 + i * 0.42, w: 3.9, h: 0.3,
      fontSize: 9.5, color: C.white, fontFace: "Calibri", valign: "middle",
    });
  });
}

// ============================================================================
//  SLIDE 3 — SECTION DIVIDER: PH
// ============================================================================
{
  const s = pres.addSlide();
  addSectionDivider(s, "01", "Pulmonary Hypertension", "Classification, Pathophysiology, Diagnosis & Management");
}

// ============================================================================
//  SLIDE 4 — PH: DEFINITION & WHO CLASSIFICATION
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "Pulmonary Hypertension: Definition & WHO Classification", "WHO/ESC/ERS 2022 | Updated definition: mPAP > 20 mmHg at rest");

  // Definition box
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.38, w: 9.4, h: 0.7, fill: { color: C.navy }, rectRadius: 0.06 });
  s.addText([
    { text: "Definition: ", options: { bold: true, color: C.gold } },
    { text: "Mean pulmonary arterial pressure (mPAP) > 20 mmHg at rest (right heart catheterization). Pre-capillary PH: mPAP >20 + PAWP ≤15 + PVR ≥2 WU. Post-capillary PH: mPAP >20 + PAWP >15.", options: { color: C.white } },
  ], { x: 0.35, y: 1.4, w: 9.3, h: 0.66, fontFace: "Calibri", fontSize: 11.5, valign: "middle" });

  // WHO Groups
  const groups = [
    { grp: "Group 1", title: "Pulmonary Arterial Hypertension (PAH)", desc: "Idiopathic, heritable, drug-induced, CTD, CHD, HIV, portal HTN", color: C.teal },
    { grp: "Group 2", title: "PH due to Left Heart Disease", desc: "HF with preserved/reduced EF, valvular disease", color: C.tealLight },
    { grp: "Group 3", title: "PH due to Lung Disease / Hypoxia", desc: "COPD, ILD, SDB, high altitude exposure", color: C.green },
    { grp: "Group 4", title: "CTEPH & Other Pulmonary Artery Obstructions", desc: "Chronic Thromboembolic PH – potentially surgically curable!", color: C.orange },
    { grp: "Group 5", title: "PH with Unclear/Multifactorial Mechanisms", desc: "Hematologic, systemic, metabolic disorders", color: C.red },
  ];

  groups.forEach((g, i) => {
    const x = i < 3 ? 0.3 : (i === 3 ? 0.3 : 5.3);
    const y = i < 3 ? 2.2 + i * 0.95 : (i === 3 ? 2.2 : 2.2);
    const w = i < 3 ? 9.4 : 4.5;
    if (i === 4) {
      // reposition group 5
    }

    // Draw for i < 3 full width, i=3 and i=4 side by side
    let fx, fy, fw;
    if (i < 3) { fx = 0.3; fy = 2.17 + i * 0.86; fw = 9.4; }
    else if (i === 3) { fx = 0.3; fy = 2.17 + 3 * 0.86; fw = 4.6; }
    else { fx = 5.1; fy = 2.17 + 3 * 0.86; fw = 4.6; }

    s.addShape(pres.ShapeType.rect, { x: fx, y: fy, w: 0.08, h: 0.75, fill: { color: g.color } });
    s.addShape(pres.ShapeType.roundRect, { x: fx + 0.08, y: fy, w: fw - 0.08, h: 0.75, fill: { color: C.white }, rectRadius: 0.03 });
    s.addText(g.grp, { x: fx + 0.15, y: fy + 0.04, w: fw - 0.25, h: 0.25, fontSize: 9, bold: true, color: g.color, fontFace: "Calibri", margin: 0 });
    s.addText(g.title, { x: fx + 0.15, y: fy + 0.25, w: fw - 0.25, h: 0.25, fontSize: 10.5, bold: true, color: C.darkText, fontFace: "Calibri", margin: 0 });
    s.addText(g.desc, { x: fx + 0.15, y: fy + 0.48, w: fw - 0.25, h: 0.22, fontSize: 8.5, color: C.midGray, fontFace: "Calibri", margin: 0, italic: true });
  });
}

// ============================================================================
//  SLIDE 5 — PH PATHOPHYSIOLOGY
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "Pathophysiology of Pulmonary Hypertension", "Vascular remodeling, endothelial dysfunction & right heart failure");

  // Left column: pathways
  s.addText("Key Pathological Mechanisms", {
    x: 0.3, y: 1.32, w: 5.2, h: 0.35,
    fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri",
  });

  const mechanisms = [
    ["Endothelial Dysfunction", "↓ NO & prostacyclin → vasoconstriction; ↑ Endothelin-1 → proliferation"],
    ["Vascular Remodeling", "Smooth muscle hypertrophy, intima fibrosis, adventitial remodeling → ↑ PVR"],
    ["Thrombosis In Situ", "Pro-coagulant state, platelet activation → microvascular obstruction"],
    ["Inflammation", "Macrophage, T-cell infiltration; cytokines (IL-6, TNF-α) drive progression"],
    ["Genetic Factors", "BMPR2 mutation (heritable PAH) → impaired TGF-β signaling in ~75% familial PAH"],
    ["Right Ventricular Failure", "Chronic pressure overload → RV hypertrophy → dilatation → failure"],
  ];

  mechanisms.forEach(([title, desc], i) => {
    const fy = 1.75 + i * 0.6;
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: fy, w: 5.0, h: 0.52, fill: { color: C.white }, rectRadius: 0.04 });
    s.addShape(pres.ShapeType.rect, { x: 0.3, y: fy, w: 0.07, h: 0.52, fill: { color: i % 2 === 0 ? C.teal : C.gold } });
    s.addText(title, { x: 0.45, y: fy + 0.03, w: 4.7, h: 0.2, fontSize: 10, bold: true, color: C.darkText, fontFace: "Calibri", margin: 0 });
    s.addText(desc, { x: 0.45, y: fy + 0.25, w: 4.7, h: 0.2, fontSize: 8.5, color: C.midGray, fontFace: "Calibri", margin: 0 });
  });

  // Right column: image
  if (imgs[0] && imgs[0].base64) {
    s.addImage({ data: imgs[0].base64, x: 5.55, y: 1.32, w: 4.1, h: 3.0 });
  }
  s.addText("PH: Vascular Remodeling", {
    x: 5.55, y: 4.35, w: 4.1, h: 0.3,
    fontSize: 8, italic: true, color: C.midGray, fontFace: "Calibri", align: "center",
  });

  // Hemodynamic consequence arrow
  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 5.2, w: 9.4, h: 0.22, fill: { color: C.navy } });
  s.addText("Net result: ↑ PVR → ↑ RV afterload → RV failure → ↓ cardiac output → death if untreated", {
    x: 0.35, y: 5.2, w: 9.3, h: 0.22,
    fontSize: 9.5, color: C.gold, fontFace: "Calibri", bold: true, align: "center",
  });
}

// ============================================================================
//  SLIDE 6 — PH: CLINICAL FEATURES & DIAGNOSIS
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "Pulmonary Hypertension: Clinical Features & Diagnosis");

  // Left: symptoms + signs
  s.addText("Symptoms", { x: 0.3, y: 1.32, w: 3.2, h: 0.3, fontSize: 12, bold: true, color: C.teal, fontFace: "Calibri" });
  addBullets(s, [
    "Exertional dyspnea (earliest, most common)",
    "Fatigue & exercise intolerance",
    "Chest pain (angina-like – RV ischemia)",
    "Syncope / pre-syncope (severe PH, low CO)",
    "Hemoptysis (rare, pulmonary artery rupture)",
    "Symptoms of right heart failure (late)",
  ], 0.3, 1.65, 3.2, 2.0, { fontSize: 11, color: C.darkText });

  s.addText("Physical Signs", { x: 0.3, y: 3.72, w: 3.2, h: 0.3, fontSize: 12, bold: true, color: C.teal, fontFace: "Calibri" });
  addBullets(s, [
    "Loud P2, right-sided S3/S4",
    "RV heave, elevated JVP",
    "Tricuspid regurgitation murmur",
    "Peripheral edema, ascites (late)",
  ], 0.3, 4.05, 3.2, 1.4, { fontSize: 11, color: C.darkText });

  // Center: investigations
  s.addShape(pres.ShapeType.rect, { x: 3.65, y: 1.25, w: 0.04, h: 4.2, fill: { color: C.gold } });
  s.addText("Diagnostic Workup", { x: 3.78, y: 1.32, w: 5.9, h: 0.3, fontSize: 12, bold: true, color: C.teal, fontFace: "Calibri" });

  const diags = [
    { label: "ECG", detail: "RV strain, RAD, RBBB, P pulmonale" },
    { label: "CXR", detail: "Enlarged central PA, peripheral pruning, cardiomegaly" },
    { label: "Echo (TTE)", detail: "Screening test: RVSP >35 mmHg suspect PH. RV size/function, TR jet" },
    { label: "V/Q Scan", detail: "ESSENTIAL in PH workup – rules out CTEPH (high sensitivity ~96%)" },
    { label: "HRCT Chest", detail: "Identify parenchymal lung disease (Group 3), mosaic attenuation (CTEPH)" },
    { label: "PFTs + 6MWT", detail: "Lung disease, exercise capacity, prognosis" },
    { label: "Labs", detail: "BNP/NT-proBNP, ANA, HIV, LFTs, thyroid, coagulation screen" },
    { label: "RHC (Gold Std)", detail: "MANDATORY for definitive PH diagnosis & hemodynamic classification" },
    { label: "CTPA / Pulm Angio", detail: "Operative/interventional planning for CTEPH" },
  ];

  diags.forEach((d, i) => {
    const fy = 1.7 + i * 0.43;
    s.addShape(pres.ShapeType.roundRect, { x: 3.78, y: fy, w: 5.85, h: 0.38, fill: { color: C.white }, rectRadius: 0.04 });
    s.addText(d.label + ": ", { x: 3.85, y: fy + 0.05, w: 1.0, h: 0.28, fontSize: 10, bold: true, color: C.navy, fontFace: "Calibri", margin: 0 });
    s.addText(d.detail, { x: 4.8, y: fy + 0.05, w: 4.75, h: 0.28, fontSize: 9.5, color: C.darkText, fontFace: "Calibri", margin: 0 });
  });
}

// ============================================================================
//  SLIDE 7 — PH MANAGEMENT & TARGETED THERAPY
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "PAH: Management Strategies & Targeted Therapy", "ESC/ERS 2022 Guidelines | Risk-stratified treatment");

  // General measures box
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.32, w: 9.4, h: 0.55, fill: { color: C.navy }, rectRadius: 0.05 });
  s.addText("General: Exercise training • Avoid pregnancy • Supplemental O₂ (SaO₂ <91%) • Anticoagulation (select PAH subtypes) • Diuretics • Digoxin (RV failure) • Iron repletion", {
    x: 0.4, y: 1.35, w: 9.2, h: 0.5, fontSize: 10, color: C.cream, fontFace: "Calibri", valign: "middle",
  });

  // Three pathway boxes
  const pathways = [
    {
      title: "Endothelin Pathway",
      sub: "ET-1 antagonists",
      drugs: ["Ambrisentan (selective ERA)", "Bosentan (non-selective ERA)", "Macitentan (non-selective ERA)", "↓ Vasoconstriction & remodeling"],
      color: C.teal,
    },
    {
      title: "Nitric Oxide–cGMP",
      sub: "PDE5i / sGC stimulators",
      drugs: ["Sildenafil (PDE5 inhibitor)", "Tadalafil (PDE5 inhibitor)", "Riociguat (sGC stimulator)", "↑ Vasodilation"],
      color: C.navy,
    },
    {
      title: "Prostacyclin Pathway",
      sub: "PGI₂ analogues & receptor agonists",
      drugs: ["Epoprostenol IV (most effective)", "Treprostinil SC/IV/inhaled/oral", "Iloprost (inhaled)", "Selexipag (oral IP receptor agonist)"],
      color: C.orange,
    },
  ];

  pathways.forEach((p, i) => {
    const fx = 0.3 + i * 3.22;
    s.addShape(pres.ShapeType.roundRect, { x: fx, y: 1.98, w: 3.1, h: 3.4, fill: { color: p.color }, rectRadius: 0.07 });
    s.addText(p.title, { x: fx + 0.1, y: 2.04, w: 2.9, h: 0.38, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
    s.addText(p.sub, { x: fx + 0.1, y: 2.42, w: 2.9, h: 0.28, fontSize: 9, italic: true, color: C.cream, fontFace: "Calibri", align: "center" });
    s.addShape(pres.ShapeType.rect, { x: fx + 0.2, y: 2.72, w: 2.7, h: 0.04, fill: { color: C.gold } });
    p.drugs.forEach((drug, j) => {
      s.addText("• " + drug, { x: fx + 0.18, y: 2.82 + j * 0.47, w: 2.85, h: 0.42, fontSize: 10, color: C.white, fontFace: "Calibri" });
    });
  });

  // Image (PAH therapy diagram)
  if (imgs[1] && imgs[1].base64) {
    // Add as small thumbnail bottom right
    s.addImage({ data: imgs[1].base64, x: 9.55, y: 1.98, w: 0.35, h: 0.35 }); // tiny placeholder
  }

  // Surgical/interventional note
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 5.2, w: 9.4, h: 0.28, fill: { color: C.gold }, rectRadius: 0.04 });
  s.addText("Advanced: Lung transplantation (refractory PAH) | BPA (balloon pulmonary angioplasty – CTEPH) | PTE surgery (CTEPH, potentially curative)", {
    x: 0.4, y: 5.2, w: 9.2, h: 0.28, fontSize: 9.5, bold: true, color: C.navy, fontFace: "Calibri", align: "center",
  });
}

// ============================================================================
//  SLIDE 8 — SECTION DIVIDER: VTE
// ============================================================================
{
  const s = pres.addSlide();
  addSectionDivider(s, "02", "Venous Thromboembolism", "DVT, Pulmonary Embolism & CTEPH – Pathophysiology to Management");
}

// ============================================================================
//  SLIDE 9 — DVT: EPIDEMIOLOGY & PATHOPHYSIOLOGY
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "Deep Vein Thrombosis (DVT): Pathophysiology & Risk Factors", "VTE = DVT + Pulmonary Embolism | ~470,000 PE hospitalizations/year (USA)");

  // Virchow's triad – large central display
  s.addText("VIRCHOW'S TRIAD", {
    x: 3.5, y: 1.38, w: 3, h: 0.38,
    fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri", align: "center", charSpacing: 2,
  });

  const triads = [
    { title: "STASIS", icon: "🩸", items: ["Prolonged immobility", "Long-haul flight/travel", "Pregnancy (gravid uterus)", "Heart failure, paralysis"], color: C.teal, x: 0.2 },
    { title: "HYPERCOAGULABILITY", icon: "⚗️", items: ["Factor V Leiden, Prot C/S def.", "Antiphospholipid syndrome", "Malignancy (Trousseau's)", "OCP / HRT, pregnancy"], color: C.navy, x: 3.55 },
    { title: "ENDOTHELIAL INJURY", icon: "🔬", items: ["Surgery / trauma", "IV catheter / device", "Vasculitis", "Prior DVT"], color: C.orange, x: 6.9 },
  ];

  triads.forEach((t, i) => {
    s.addShape(pres.ShapeType.roundRect, { x: t.x, y: 1.85, w: 3.0, h: 3.55, fill: { color: t.color }, rectRadius: 0.08 });
    s.addText(t.icon, { x: t.x, y: 1.9, w: 3.0, h: 0.5, fontSize: 22, align: "center", fontFace: "Segoe UI Emoji" });
    s.addText(t.title, { x: t.x + 0.1, y: 2.42, w: 2.8, h: 0.38, fontSize: 11.5, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
    s.addShape(pres.ShapeType.rect, { x: t.x + 0.4, y: 2.82, w: 2.2, h: 0.04, fill: { color: C.gold } });
    t.items.forEach((item, j) => {
      s.addText("• " + item, { x: t.x + 0.15, y: 2.92 + j * 0.54, w: 2.7, h: 0.5, fontSize: 10, color: C.cream, fontFace: "Calibri" });
    });
  });
}

// ============================================================================
//  SLIDE 10 — DVT: DIAGNOSIS & MANAGEMENT
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "DVT: Diagnosis & Management");

  // Left: Wells Score
  s.addText("Wells Score for DVT Pre-test Probability", {
    x: 0.3, y: 1.32, w: 4.6, h: 0.32, fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri",
  });

  const wellsDVT = [
    ["Active cancer", "+1"],
    ["Paralysis / plaster cast", "+1"],
    ["Bedridden >3 days / surgery <4 wks", "+1"],
    ["Localized tenderness along deep veins", "+1"],
    ["Entire leg swollen", "+1"],
    ["Calf swelling >3 cm (vs. other leg)", "+1"],
    ["Pitting edema", "+1"],
    ["Collateral superficial veins", "+1"],
    ["Alternative diagnosis as likely", "−2"],
  ];
  const scoreInterp = [
    ["Score ≥2", "High probability (75%)"],
    ["Score 1", "Moderate (17%)"],
    ["Score ≤0", "Low probability (3%)"],
  ];

  wellsDVT.forEach(([item, score], i) => {
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.68 + i * 0.34, w: 3.8, h: 0.3, fill: { color: C.white }, rectRadius: 0.03 });
    s.addText(item, { x: 0.38, y: 1.7 + i * 0.34, w: 3.1, h: 0.26, fontSize: 9.5, color: C.darkText, fontFace: "Calibri", margin: 0 });
    s.addText(score, { x: 3.5, y: 1.7 + i * 0.34, w: 0.55, h: 0.26, fontSize: 10, bold: true, color: score.includes("-") ? C.red : C.green, fontFace: "Calibri", align: "center", margin: 0 });
  });

  scoreInterp.forEach(([sc, interp], i) => {
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 4.82 + i * 0.0, w: 1.7, h: 0.2 * 0, fill: { color: C.gold }, rectRadius: 0 });
  });
  s.addText(scoreInterp.map(x => x[0] + ": " + x[1]).join("  |  "), {
    x: 0.3, y: 4.82, w: 4.5, h: 0.25, fontSize: 9, color: C.navy, fontFace: "Calibri", bold: true,
  });

  // Right: Ultrasound image + management
  if (imgs[3] && imgs[3].base64) {
    s.addImage({ data: imgs[3].base64, x: 5.0, y: 1.35, w: 4.65, h: 2.0 });
    s.addText("DVT on duplex ultrasound – non-compressible vein with echogenic thrombus", {
      x: 5.0, y: 3.38, w: 4.65, h: 0.25, fontSize: 8, italic: true, color: C.midGray, fontFace: "Calibri", align: "center",
    });
  }

  s.addText("Management", { x: 5.0, y: 3.7, w: 4.65, h: 0.3, fontSize: 12, bold: true, color: C.teal, fontFace: "Calibri" });
  addBullets(s, [
    "Anticoagulate for minimum 3 months (provoked DVT)",
    "DOACs (rivaroxaban, apixaban) preferred over warfarin",
    "LMWH for cancer-associated VTE (or DOAC if low bleed risk)",
    "Extended therapy for unprovoked DVT (risk vs benefit discussion)",
    "Compression stockings for symptom relief",
    "CDT / thrombectomy for massive ilio-femoral DVT (select cases)",
  ], 5.0, 4.02, 4.65, 1.5, { fontSize: 10.5, color: C.darkText });
}

// ============================================================================
//  SLIDE 11 — PE: PATHOPHYSIOLOGY & RISK CLASSIFICATION
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "Pulmonary Embolism: Pathophysiology & Epidemiology", "~470,000 PE hospitalizations/year in USA | 1 in 5 high-risk patients die (AHA 2026)");

  // Pathophysiology flow
  s.addText("Pathophysiological Cascade", { x: 0.3, y: 1.32, w: 5.5, h: 0.32, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri" });

  const cascade = [
    { step: "Thrombus in deep vein", detail: "Proximal DVT (ilio-femoral) → highest risk of embolism" },
    { step: "Embolism to pulmonary artery", detail: "Mechanical obstruction + reflex vasoconstriction (hypoxia, serotonin, TXA₂)" },
    { step: "↑ Pulmonary Vascular Resistance", detail: "Acute RV pressure overload → RV dilation & tricuspid regurgitation" },
    { step: "RV-LV Interdependence Failure", detail: "Septal shift → ↓ LV filling → ↓ CO → systemic hypotension" },
    { step: "Hemodynamic Collapse", detail: "Obstructive shock; RV ischemia compounds failure (massive PE)" },
    { step: "Lung Consequences", detail: "Dead space ↑, hypoxia (V/Q mismatch), atelectasis, pulmonary infarct in ~10%" },
  ];

  cascade.forEach((step, i) => {
    const fy = 1.7 + i * 0.58;
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: fy, w: 5.3, h: 0.5, fill: { color: C.white }, rectRadius: 0.04 });
    s.addShape(pres.ShapeType.rect, { x: 0.3, y: fy, w: 0.07, h: 0.5, fill: { color: i < 2 ? C.teal : i < 4 ? C.orange : C.red } });
    s.addText(`${i + 1}. ${step.step}`, { x: 0.45, y: fy + 0.03, w: 5.05, h: 0.22, fontSize: 10, bold: true, color: C.darkText, fontFace: "Calibri", margin: 0 });
    s.addText(step.detail, { x: 0.45, y: fy + 0.26, w: 5.05, h: 0.18, fontSize: 8.5, color: C.midGray, fontFace: "Calibri", margin: 0 });
  });

  // Right: CTPA image
  if (imgs[2] && imgs[2].base64) {
    s.addImage({ data: imgs[2].base64, x: 5.85, y: 1.35, w: 3.8, h: 2.8 });
    s.addText("CTPA: Bilateral filling defects – acute PE", {
      x: 5.85, y: 4.18, w: 3.8, h: 0.25, fontSize: 8, italic: true, color: C.midGray, fontFace: "Calibri", align: "center",
    });
  }

  // Risk factor panel
  s.addShape(pres.ShapeType.roundRect, { x: 5.85, y: 4.5, w: 3.8, h: 0.9, fill: { color: C.navy }, rectRadius: 0.05 });
  s.addText("Major Risk Factors", { x: 5.95, y: 4.52, w: 3.6, h: 0.25, fontSize: 10, bold: true, color: C.gold, fontFace: "Calibri" });
  s.addText("Surgery/hospitalization • Trauma • Immobility >3 days • Pregnancy/postpartum • Malignancy • Prior VTE • Obesity (BMI >30) • OCP/HRT", {
    x: 5.95, y: 4.78, w: 3.6, h: 0.55, fontSize: 8.5, color: C.cream, fontFace: "Calibri",
  });
}

// ============================================================================
//  SLIDE 12 — PE DIAGNOSIS: 2026 AHA/ACC CATEGORIES
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "PE Diagnosis: 2026 AHA/ACC Clinical Category System", "NEW 2026 guideline: 5-category A–E system replaces massive/submassive/low-risk");

  // New category system
  s.addText("2026 AHA/ACC Acute PE Clinical Categories", {
    x: 0.3, y: 1.32, w: 9.4, h: 0.32, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri",
  });

  const categories = [
    { cat: "A", desc: "Incidental / sub-segmental PE", features: "Asymptomatic, found incidentally; subsegmental (B1) vs segmental+ (B2)", color: C.green, sev: "Lowest Risk" },
    { cat: "B", desc: "Low clinical severity", features: "Symptomatic; PESI ≤85 or sPESI 0; no RV dysfunction or biomarker elevation", color: C.tealLight, sev: "Low Risk" },
    { cat: "C", desc: "Elevated risk – no shock", features: "PESI >85 or sPESI ≥1; ± ↑ troponin/BNP; ± RV dysfunction on echo/CT", color: C.gold, sev: "Intermediate Risk" },
    { cat: "D", desc: "Hemodynamic compromise", features: "SBP <90 or drop >40 mmHg for >15 min; not yet in refractory shock", color: C.orange, sev: "High Risk" },
    { cat: "E", desc: "Refractory obstructive shock / arrest", features: "CPR required; cardiac arrest; refractory hypotension despite resuscitation", color: C.red, sev: "Highest Risk" },
  ];

  categories.forEach((cat, i) => {
    const fy = 1.72 + i * 0.73;
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: fy, w: 0.55, h: 0.62, fill: { color: cat.color }, rectRadius: 0.06 });
    s.addText(cat.cat, { x: 0.3, y: fy + 0.1, w: 0.55, h: 0.42, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
    s.addShape(pres.ShapeType.roundRect, { x: 0.92, y: fy, w: 9.0, h: 0.62, fill: { color: C.white }, rectRadius: 0.04 });
    s.addText(cat.desc, { x: 1.0, y: fy + 0.03, w: 5.5, h: 0.27, fontSize: 11, bold: true, color: C.darkText, fontFace: "Calibri", margin: 0 });
    s.addText(cat.features, { x: 1.0, y: fy + 0.32, w: 5.5, h: 0.25, fontSize: 9, color: C.midGray, fontFace: "Calibri", margin: 0 });
    s.addShape(pres.ShapeType.roundRect, { x: 6.55, y: fy + 0.12, w: 3.2, h: 0.38, fill: { color: cat.color }, rectRadius: 0.04 });
    s.addText(cat.sev, { x: 6.55, y: fy + 0.12, w: 3.2, h: 0.38, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  });

  // D-dimer / PERC note
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 5.3, w: 9.4, h: 0.22, fill: { color: C.teal }, rectRadius: 0.04 });
  s.addText("Diagnostic algorithm: PERC rule (if low pretest probability) → D-dimer → CTPA (gold standard) | V/Q scan if CTPA contraindicated", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.22, fontSize: 9, color: C.white, fontFace: "Calibri", align: "center",
  });
}

// ============================================================================
//  SLIDE 13 — WELLS SCORE FOR PE + PERC
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "PE Risk Stratification: Wells Score & PERC Rule");

  // Wells PE Score
  s.addText("Wells Criteria for PE", { x: 0.3, y: 1.32, w: 4.5, h: 0.32, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri" });

  const wellsPE = [
    ["Clinical signs/symptoms of DVT", "3.0"],
    ["PE is #1 diagnosis or equally likely", "3.0"],
    ["Heart rate >100 bpm", "1.5"],
    ["Immobilization >3 days / surgery <4 wks", "1.5"],
    ["Previous DVT or PE", "1.5"],
    ["Hemoptysis", "1.0"],
    ["Malignancy (on treatment or palliative)", "1.0"],
  ];

  wellsPE.forEach(([item, score], i) => {
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.7 + i * 0.42, w: 4.5, h: 0.38, fill: { color: C.white }, rectRadius: 0.03 });
    s.addText(item, { x: 0.4, y: 1.73 + i * 0.42, w: 3.55, h: 0.3, fontSize: 10, color: C.darkText, fontFace: "Calibri", margin: 0 });
    s.addText(score, { x: 4.0, y: 1.73 + i * 0.42, w: 0.75, h: 0.3, fontSize: 11, bold: true, color: C.teal, fontFace: "Calibri", align: "center", margin: 0 });
  });

  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 4.68, w: 4.5, h: 0.68, fill: { color: C.navy }, rectRadius: 0.05 });
  s.addText([
    { text: "Score ≤4: ", options: { bold: true, color: C.gold } },
    { text: "Low (use D-dimer)  ", options: { color: C.white } },
    { text: "Score >4: ", options: { bold: true, color: C.gold } },
    { text: "High – proceed to CTPA", options: { color: C.white } },
  ], { x: 0.4, y: 4.72, w: 4.3, h: 0.55, fontSize: 10, fontFace: "Calibri" });

  // PERC Rule
  s.addText("PERC Rule (use only in LOW pretest probability)", {
    x: 5.0, y: 1.32, w: 4.65, h: 0.32, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri",
  });

  const percItems = [
    "Age <50 years",
    "HR <100 bpm",
    "O₂ sat ≥95% on room air",
    "No unilateral leg swelling",
    "No hemoptysis",
    "No recent trauma or surgery",
    "No prior DVT / PE",
    "No hormone use (OCP, HRT, testosterone)",
  ];

  percItems.forEach((item, i) => {
    s.addShape(pres.ShapeType.roundRect, { x: 5.0, y: 1.7 + i * 0.38, w: 4.65, h: 0.34, fill: { color: C.white }, rectRadius: 0.03 });
    s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.7 + i * 0.38, w: 0.06, h: 0.34, fill: { color: C.green } });
    s.addText("✓  " + item, { x: 5.1, y: 1.73 + i * 0.38, w: 4.5, h: 0.28, fontSize: 10, color: C.darkText, fontFace: "Calibri", margin: 0 });
  });

  s.addShape(pres.ShapeType.roundRect, { x: 5.0, y: 4.75, w: 4.65, h: 0.6, fill: { color: C.green }, rectRadius: 0.05 });
  s.addText("If ALL 8 criteria met → PERC negative → D-dimer NOT needed → PE excluded\nIf ANY criterion fails → order D-dimer or CTPA", {
    x: 5.1, y: 4.78, w: 4.45, h: 0.55, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri",
  });
}

// ============================================================================
//  SLIDE 14 — PE MANAGEMENT (2026 AHA/ACC GUIDELINES)
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "PE Management: 2026 AHA/ACC Guideline Recommendations", "First dedicated PE guideline from AHA/ACC – published February 2026");

  // Anticoagulation box
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.35, w: 9.4, h: 0.62, fill: { color: C.navy }, rectRadius: 0.05 });
  s.addText([
    { text: "ANTICOAGULATION (Foundation of Therapy)  ", options: { bold: true, color: C.gold } },
    { text: "Start immediately in all confirmed PE without absolute contraindication (Class I, LOE B-R)", options: { color: C.white } },
  ], { x: 0.4, y: 1.38, w: 9.1, h: 0.58, fontSize: 10.5, fontFace: "Calibri", valign: "middle" });

  const mgmtRows = [
    {
      title: "Category B (Low Risk)", color: C.green,
      items: ["DOAC preferred (rivaroxaban, apixaban, edoxaban, dabigatran)", "Consider outpatient treatment if Hestia <1 / sPESI = 0", "Avoid systemic thrombolysis", "Duration: ≥3 months (provoked); discuss extended for unprovoked"],
    },
    {
      title: "Category C (Intermediate Risk)", color: C.gold,
      items: ["DOAC or LMWH → oral anticoagulation", "RV imaging (echo/CT) – Class I, LOE A", "Biomarkers (troponin, BNP) for risk stratification", "Consider PERT (PE Response Team) activation", "Monitor closely; advanced therapy if deterioration"],
    },
    {
      title: "Category D–E (High / Highest Risk)", color: C.red,
      items: ["Systemic thrombolysis (tPA) if no contraindication – Class I", "Surgical embolectomy or catheter-directed therapy if thrombolysis fails/contraindicated", "Extracorporeal membrane oxygenation (ECMO) for refractory shock", "UFH preferred over LMWH in hemodynamically unstable patients"],
    },
  ];

  mgmtRows.forEach((row, i) => {
    const fy = 2.05 + i * 1.13;
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: fy, w: 9.4, h: 1.05, fill: { color: C.white }, rectRadius: 0.05 });
    s.addShape(pres.ShapeType.rect, { x: 0.3, y: fy, w: 0.07, h: 1.05, fill: { color: row.color } });
    s.addText(row.title, { x: 0.45, y: fy + 0.04, w: 9.1, h: 0.26, fontSize: 11, bold: true, color: row.color, fontFace: "Calibri", margin: 0 });
    const bullets = row.items.map((item, j) => ({
      text: "• " + item,
      options: { fontSize: 9.5, color: C.darkText, breakLine: j < row.items.length - 1, paraSpaceAfter: 1 },
    }));
    s.addText(bullets, { x: 0.45, y: fy + 0.32, w: 9.1, h: 0.68, fontFace: "Calibri", valign: "top" });
  });

  // Footer note
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 5.38, w: 9.4, h: 0.2, fill: { color: C.teal }, rectRadius: 0.03 });
  s.addText("IVC filter: NOT recommended in adequately anticoagulated patients (Class III Harm, LOE A) | Follow-up within 1 week post-discharge (Class I)", {
    x: 0.4, y: 5.38, w: 9.2, h: 0.2, fontSize: 8.5, color: C.white, fontFace: "Calibri", align: "center",
  });
}

// ============================================================================
//  SLIDE 15 — ANTICOAGULANT DRUG COMPARISON
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "Anticoagulation for VTE: Drug Comparison", "DOACs now preferred – 2026 AHA/ACC & ESC 2019 guidelines");

  const headers = ["Agent", "Mechanism", "VTE Dose", "Reversal", "Key Notes"];
  const rows = [
    ["Apixaban\n(Eliquis)", "FXa inhibitor", "10 mg BD ×7d → 5 mg BD", "Andexanet alfa", "No renal adj. needed <25 mL/min avoidance; preferred"],
    ["Rivaroxaban\n(Xarelto)", "FXa inhibitor", "15 mg BD ×21d → 20 mg OD", "Andexanet alfa", "Take with food; avoidance CrCl <30"],
    ["Dabigatran\n(Pradaxa)", "Direct thrombin inhibitor", "Parenteral 5-10d → 150 mg BD", "Idarucizumab", "Renal-dependent; avoid if CrCl <30"],
    ["Edoxaban\n(Lixiana)", "FXa inhibitor", "Parenteral 5-10d → 60 mg OD", "Andexanet alfa", "Reduce dose if wt <60 kg, certain drugs"],
    ["LMWH\n(e.g. Enoxaparin)", "Anti-FXa/FIIa", "1 mg/kg SC BD", "Protamine (partial)", "Preferred: cancer, pregnancy, renal failure"],
    ["UFH\n(Heparin)", "Anti-FXa/FIIa", "80 U/kg IV bolus → infusion", "Protamine", "Hemodynamic instability, massive PE, renal failure"],
    ["Warfarin", "Vitamin K antagonist", "INR 2–3", "Vit K / FFP / 4F-PCC", "Pregnancy X; interactions; bridging needed"],
  ];

  const colWidths = [1.1, 1.4, 1.9, 1.3, 3.8];
  const colX = [0.15, 1.3, 2.75, 4.7, 6.05];

  // Header row
  s.addShape(pres.ShapeType.rect, { x: 0.15, y: 1.35, w: 9.7, h: 0.38, fill: { color: C.navy } });
  headers.forEach((h, ci) => {
    s.addText(h, { x: colX[ci] + 0.05, y: 1.37, w: colWidths[ci] - 0.05, h: 0.34, fontSize: 10, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle", margin: 0 });
  });

  rows.forEach((row, ri) => {
    const fy = 1.75 + ri * 0.53;
    const bg = ri % 2 === 0 ? C.white : "EEF6FB";
    s.addShape(pres.ShapeType.rect, { x: 0.15, y: fy, w: 9.7, h: 0.5, fill: { color: bg } });
    row.forEach((cell, ci) => {
      const isFirst = ci === 0;
      s.addText(cell, {
        x: colX[ci] + 0.05, y: fy + 0.03, w: colWidths[ci] - 0.05, h: 0.44,
        fontSize: 9, color: isFirst ? C.navy : C.darkText, fontFace: "Calibri",
        bold: isFirst, valign: "middle", margin: 0,
      });
    });
  });

  s.addShape(pres.ShapeType.roundRect, { x: 0.15, y: 5.42, w: 9.7, h: 0.18, fill: { color: C.gold }, rectRadius: 0.03 });
  s.addText("Pregnancy: LMWH only | Cancer: DOAC (apixaban/rivaroxaban) or LMWH | Antiphospholipid syndrome: Warfarin (DOAC less effective for triple-positive APS)", {
    x: 0.25, y: 5.42, w: 9.5, h: 0.18, fontSize: 8, color: C.navy, fontFace: "Calibri", align: "center", bold: true,
  });
}

// ============================================================================
//  SLIDE 16 — CTEPH
// ============================================================================
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "CTEPH: Chronic Thromboembolic Pulmonary Hypertension", "WHO Group 4 PH | Unique: potentially surgically curable");

  // Key facts
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.35, w: 9.4, h: 0.5, fill: { color: C.navy }, rectRadius: 0.05 });
  s.addText("CTEPH develops in ~4% after acute PE | ~25% have no documented prior PE | Diagnosis requires mPAP >20 mmHg + V/Q perfusion defects after ≥3 months anticoagulation", {
    x: 0.4, y: 1.38, w: 9.2, h: 0.45, fontSize: 10, color: C.cream, fontFace: "Calibri", valign: "middle",
  });

  // Left: Pathogenesis
  s.addText("Pathogenesis", { x: 0.3, y: 1.95, w: 3.2, h: 0.3, fontSize: 11, bold: true, color: C.teal, fontFace: "Calibri" });
  addBullets(s, [
    "Incomplete resolution of pulmonary thromboemboli",
    "Fibro-inflammatory intravascular scar formation",
    "Endothelial dysfunction → ↑ ET-1",
    "Secondary small-vessel vasculopathy worsens PH",
    "Fails normal fibrinolysis (fibrin structure abnormalities)",
    "Risk factors: Lupus AC, ↑ FVIII, malignancy, thyroid disease",
  ], 0.3, 2.28, 3.2, 3.0, { fontSize: 10.5 });

  // Center: Diagnosis
  s.addText("Diagnosis", { x: 3.65, y: 1.95, w: 3.0, h: 0.3, fontSize: 11, bold: true, color: C.teal, fontFace: "Calibri" });
  addBullets(s, [
    "V/Q scan: High sensitivity (~97%) for CTEPH",
    "CTPA: Identifies proximal disease, operability",
    "RHC: Mandatory (confirms mPAP, PVR, PAWP)",
    "Pulmonary angiography: Pre-op planning",
    "Echo: Initial screening; RV dysfunction",
    "Mismatched perfusion defects = hallmark",
  ], 3.65, 2.28, 3.0, 3.0, { fontSize: 10.5 });

  // Right: Treatment
  s.addText("Treatment", { x: 6.85, y: 1.95, w: 2.9, h: 0.3, fontSize: 11, bold: true, color: C.teal, fontFace: "Calibri" });
  const txItems = [
    { label: "PTE Surgery", detail: "First-line if operable", color: C.green },
    { label: "Balloon Pulmonary Angioplasty (BPA)", detail: "Inoperable / residual PH post-PTE", color: C.tealLight },
    { label: "Riociguat (sGC stimulator)", detail: "Only approved medical Rx for CTEPH (Class I)", color: C.teal },
    { label: "Anticoagulation (lifelong)", detail: "All CTEPH patients", color: C.navy },
    { label: "Transplant", detail: "Refractory, inoperable, failed BPA", color: C.midGray },
  ];

  txItems.forEach((tx, i) => {
    s.addShape(pres.ShapeType.roundRect, { x: 6.85, y: 2.28 + i * 0.63, w: 2.85, h: 0.56, fill: { color: tx.color }, rectRadius: 0.05 });
    s.addText(tx.label, { x: 6.95, y: 2.3 + i * 0.63, w: 2.65, h: 0.25, fontSize: 9.5, bold: true, color: C.white, fontFace: "Calibri", margin: 0 });
    s.addText(tx.detail, { x: 6.95, y: 2.55 + i * 0.63, w: 2.65, h: 0.25, fontSize: 8.5, color: C.cream, fontFace: "Calibri", margin: 0, italic: true });
  });

  // CTEPH image
  if (imgs[4] && imgs[4].base64) {
    // Place pathophysiology diagram image if available
  }
}

// ============================================================================
//  SLIDE 17 — DURATION OF ANTICOAGULATION & EXTENDED THERAPY
// ============================================================================
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  addHeaderBar(s, "Duration of Anticoagulation: Evidence-Based Approach", "2026 AHA/ACC | ESC 2019 | CHEST Guidelines");

  const durationData = [
    { scenario: "Provoked PE (major transient risk factor, e.g. surgery)", duration: "3 months then stop", drug: "DOAC", color: C.green },
    { scenario: "Provoked PE (minor transient risk factor, e.g. travel)", duration: "3–6 months; consider extended", drug: "DOAC / Warfarin", color: C.tealLight },
    { scenario: "Unprovoked first PE (low/mod bleed risk)", duration: "Extended (indefinite)", drug: "Half-dose apixaban or rivaroxaban", color: C.gold },
    { scenario: "Recurrent unprovoked PE", duration: "Indefinite anticoagulation", drug: "DOAC preferred", color: C.orange },
    { scenario: "PE with active cancer", duration: "Indefinite (while active)", drug: "DOAC (apixaban/rivaroxaban) or LMWH", color: C.red },
    { scenario: "PE with antiphospholipid syndrome (triple positive)", duration: "Indefinite", drug: "Warfarin INR 2–3", color: C.navy },
    { scenario: "Subsegmental PE without proximal DVT", duration: "Discuss: 3 months vs watchful waiting", drug: "Shared decision", color: C.midGray },
  ];

  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.35, w: 2.8, h: 0.34, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 3.15, y: 1.35, w: 2.3, h: 0.34, fill: { color: C.teal } });
  s.addShape(pres.ShapeType.rect, { x: 5.5, y: 1.35, w: 4.2, h: 0.34, fill: { color: C.navy } });
  s.addText("Clinical Scenario", { x: 0.35, y: 1.37, w: 2.7, h: 0.3, fontSize: 10, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle", margin: 0 });
  s.addText("Duration", { x: 3.2, y: 1.37, w: 2.2, h: 0.3, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", valign: "middle", margin: 0 });
  s.addText("Preferred Agent (2026)", { x: 5.55, y: 1.37, w: 4.1, h: 0.3, fontSize: 10, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle", margin: 0 });

  durationData.forEach((row, i) => {
    const fy = 1.72 + i * 0.54;
    const bg = i % 2 === 0 ? C.white : "EEF6FB";
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: fy, w: 9.4, h: 0.49, fill: { color: bg }, rectRadius: 0.03 });
    s.addShape(pres.ShapeType.rect, { x: 0.3, y: fy, w: 0.07, h: 0.49, fill: { color: row.color } });
    s.addText(row.scenario, { x: 0.43, y: fy + 0.04, w: 2.65, h: 0.42, fontSize: 9, color: C.darkText, fontFace: "Calibri", valign: "middle", margin: 0 });
    s.addText(row.duration, { x: 3.15, y: fy + 0.04, w: 2.25, h: 0.42, fontSize: 9, bold: true, color: row.color, fontFace: "Calibri", valign: "middle", margin: 0 });
    s.addText(row.drug, { x: 5.5, y: fy + 0.04, w: 4.15, h: 0.42, fontSize: 9, color: C.darkText, fontFace: "Calibri", valign: "middle", margin: 0 });
  });

  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 5.38, w: 9.4, h: 0.2, fill: { color: C.gold }, rectRadius: 0.03 });
  s.addText("Half-dose DOAC (apixaban 2.5 mg BD or rivaroxaban 10 mg OD) after ≥6 months full anticoagulation shown non-inferior for unprovoked VTE (EINSTEIN CHOICE, AMPLIFY-EXT)", {
    x: 0.4, y: 5.38, w: 9.2, h: 0.2, fontSize: 8, bold: true, color: C.navy, fontFace: "Calibri", align: "center",
  });
}

// ============================================================================
//  SLIDE 18 — PH RISK STRATIFICATION (ESC/ERS)
// ============================================================================
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightBg } });
  addHeaderBar(s, "PAH: ESC/ERS Risk Stratification & Treatment Algorithm", "ESC/ERS 2022 Guidelines | Risk-guided therapy");

  s.addText("ESC/ERS 4-Strata Risk Assessment (1-year mortality)", {
    x: 0.3, y: 1.32, w: 9.4, h: 0.3, fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri",
  });

  const riskLevels = [
    { level: "LOW RISK", mort: "<5%/yr", features: ["WHO-FC I–II", "No syncope", "6MWD >440 m", "BNP <50 / NT-proBNP <300", "Normal RV function"], color: C.green, tx: "Oral combination therapy (ERA + PDE5i)\nMonitor every 3–6 months" },
    { level: "INTERMEDIATE-LOW", mort: "5–10%/yr", features: ["WHO-FC II–III", "6MWD 320–440 m", "BNP 50–300 / NT-proBNP 300–1400", "Mildly reduced RV function"], color: C.tealLight, tx: "Optimise oral combination or\nConsider prostacyclin pathway agent" },
    { level: "INTERMEDIATE-HIGH", mort: "10–20%/yr", features: ["WHO-FC III", "6MWD <320 m", "BNP 300–800 / NT-proBNP 1400–5000", "Moderate RV dysfunction"], color: C.orange, tx: "Add prostacyclin pathway agent\nConsider parenteral prostanoid" },
    { level: "HIGH RISK", mort: ">20%/yr", features: ["WHO-FC IV", "Syncope, RV failure", "BNP >800 / NT-proBNP >5000", "Severe RV dysfunction, low CI"], color: C.red, tx: "IV/SC prostanoid + ERA + PDE5i\nUrgent transplant listing" },
  ];

  riskLevels.forEach((r, i) => {
    const fx = 0.28 + i * 2.38;
    s.addShape(pres.ShapeType.roundRect, { x: fx, y: 1.7, w: 2.25, h: 3.7, fill: { color: r.color }, rectRadius: 0.07 });
    s.addText(r.level, { x: fx + 0.05, y: 1.74, w: 2.15, h: 0.38, fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
    s.addText(r.mort, { x: fx + 0.05, y: 2.12, w: 2.15, h: 0.28, fontSize: 9, color: C.cream, fontFace: "Calibri", align: "center", italic: true });
    s.addShape(pres.ShapeType.rect, { x: fx + 0.25, y: 2.42, w: 1.75, h: 0.04, fill: { color: C.white } });
    r.features.forEach((f, j) => {
      s.addText("• " + f, { x: fx + 0.1, y: 2.52 + j * 0.38, w: 2.05, h: 0.35, fontSize: 8.5, color: C.white, fontFace: "Calibri" });
    });
    s.addShape(pres.ShapeType.roundRect, { x: fx + 0.05, y: 4.45, w: 2.15, h: 0.82, fill: { color: C.navy }, rectRadius: 0.04 });
    s.addText(r.tx, { x: fx + 0.08, y: 4.47, w: 2.05, h: 0.78, fontSize: 8, color: C.cream, fontFace: "Calibri" });
  });

  s.addText("Reassess at 3–6 months: aim to achieve LOW risk profile. ESC/ERS 2022 recommends upfront combination therapy for most newly diagnosed PAH patients.", {
    x: 0.3, y: 5.45, w: 9.4, h: 0.15, fontSize: 8.5, color: C.navy, fontFace: "Calibri", italic: true,
  });
}

// ============================================================================
//  SLIDE 19 — SPECIAL POPULATIONS
// ============================================================================
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  addHeaderBar(s, "VTE in Special Populations");

  const populations = [
    {
      title: "Pregnancy",
      items: ["LMWH is anticoagulant of choice (whole pregnancy)", "DOACs CONTRAINDICATED (teratogenic / fetal risk)", "D-dimer less reliable; avoid CTPA if possible", "CUS → VQ scan preferred over CTPA", "Therapeutic LMWH stopped 24 hrs before delivery", "Post-partum: LMWH or warfarin (safe in breastfeeding)"],
      color: C.tealLight,
    },
    {
      title: "Cancer-Associated VTE",
      items: ["DOAC (rivaroxaban, apixaban, edoxaban) preferred if low GI bleed risk", "LMWH alternative (esp. GI or GU malignancy)", "Indefinite anticoagulation while cancer active", "Avoid DOACs in severe thrombocytopenia (<50)", "Reassess bleeding risk regularly"],
      color: C.orange,
    },
    {
      title: "Renal Impairment",
      items: ["CrCl 15–30: Apixaban or warfarin preferred", "CrCl <15: Avoid all DOACs; use warfarin or UFH", "Dabigatran 80% renal excretion – avoid CrCl <30", "UFH safe in dialysis (no renal clearance)", "LMWH – use with caution + anti-Xa monitoring"],
      color: C.navy,
    },
  ];

  populations.forEach((p, i) => {
    const fx = 0.28 + i * 3.25;
    s.addShape(pres.ShapeType.roundRect, { x: fx, y: 1.35, w: 3.1, h: 4.0, fill: { color: C.white }, rectRadius: 0.06 });
    s.addShape(pres.ShapeType.rect, { x: fx, y: 1.35, w: 3.1, h: 0.45, fill: { color: p.color }, rectRadius: 0 });
    s.addShape(pres.ShapeType.roundRect, { x: fx, y: 1.35, w: 3.1, h: 0.45, fill: { color: p.color }, rectRadius: 0.06 });
    s.addText(p.title, { x: fx + 0.1, y: 1.38, w: 2.9, h: 0.38, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
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  });

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  s.addText("APS (triple positive): Use warfarin INR 2-3, not DOAC | Obesity (BMI >40 / >120kg): Rivaroxaban/edoxaban lower plasma levels – prefer apixaban, dabigatran, or warfarin", {
    x: 0.38, y: 5.38, w: 9.24, h: 0.2, fontSize: 8, bold: true, color: C.navy, fontFace: "Calibri", align: "center",
  });
}

// ============================================================================
//  SLIDE 20 — KEY TAKEAWAYS & REFERENCES
// ============================================================================
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.12, w: 10, h: 0.08, fill: { color: C.gold } });

  s.addText("KEY TAKEAWAYS", {
    x: 0.35, y: 0.2, w: 9.3, h: 0.55,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri", align: "center", charSpacing: 3,
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  s.addText("Pulmonary Hypertension • VTE • Pulmonary Embolism", {
    x: 0.35, y: 0.75, w: 9.3, h: 0.32,
    fontSize: 11, color: C.tealLight, fontFace: "Calibri", align: "center", italic: true,
  });

  const takeaways = [
    { num: "01", text: "PH is defined as mPAP >20 mmHg (updated 2022); WHO classification has 5 groups – always determine group before treating" },
    { num: "02", text: "PAH treatment is pathway-based (ET-1, NO-cGMP, prostacyclin); upfront dual/triple combination therapy recommended for high-risk PAH (ESC/ERS 2022)" },
    { num: "03", text: "CTEPH (Group 4 PH) is uniquely curable – V/Q scan is the best screening test; riociguat + PTE surgery ± BPA are evidence-based options" },
    { num: "04", text: "2026 AHA/ACC introduced the A–E clinical category system for PE – the first dedicated PE guideline from AHA/ACC" },
    { num: "05", text: "DOACs are preferred over warfarin for most VTE treatment (Class I, LOE B-R); LMWH preferred for cancer-associated VTE and pregnancy" },
    { num: "06", text: "IVC filters are NOT recommended in adequately anticoagulated patients (Class III Harm, LOE A – 2026 AHA/ACC)" },
    { num: "07", text: "Half-dose DOAC is evidence-based for extended VTE prophylaxis (EINSTEIN CHOICE, AMPLIFY-EXT trials)" },
  ];

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    s.addText(t.text, { x: 0.97, y: fy + 0.03, w: 8.7, h: 0.44, fontSize: 10, color: C.cream, fontFace: "Calibri", valign: "middle" });
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  // References
  s.addText("References: Murray & Nadel's Respiratory Medicine | Fishman's Pulmonary Diseases | 2026 AHA/ACC PE Guideline (Creager et al., Circulation 2026) | ESC/ERS 2022 PH Guidelines | 2025 ESVM VTE Guidelines", {
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}

// ─── WRITE FILE ─────────────────────────────────────────────────────────────
const outPath = "/home/daytona/workspace/ph-vte-presentation/PH_VTE_PE_Presentation_2026.pptx";
pres.writeFile({ fileName: outPath })
  .then(() => console.log("✅ Presentation saved to: " + outPath))
  .catch(err => { console.error("❌ Error:", err); process.exit(1); });