const pptxgen = require("pptxgenjs"); const pres = new pptxgen(); pres.layout = "LAYOUT_16x9"; pres.title = "Heart Failure - Treatment Plan"; pres.author = "MBBS Final Year"; // ─── COLOR PALETTE ───────────────────────────────────────────── // Deep navy dominant, crimson accent, light gray body, white text const C = { navy: "0D1B3E", // dominant bg navyMid: "162447", // section bg crimson: "C0392B", // accent / headings crimsonSoft:"E74C3C", teal: "1A5276", gold: "F39C12", green: "1E8449", greenSoft: "27AE60", white: "FFFFFF", offWhite: "F0F3F4", grayLight: "BDC3C7", grayMid: "7F8C8D", darkText: "1C2833", boxBlue: "1F618D", boxGreen: "1E8449", boxOrange: "D35400", boxRed: "C0392B", boxPurple: "6C3483", }; // ─── HELPERS ──────────────────────────────────────────────────── function addTitle(slide, text) { slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.crimson } }); slide.addText(text, { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); } function addSectionBadge(slide, label, x, y, w, color) { slide.addShape(pres.ShapeType.rect, { x, y, w, h: 0.35, fill: { color }, line: { color, width: 0 } }); slide.addText(label, { x, y, w, h: 0.35, fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); } function addBox(slide, title, bullets, x, y, w, h, titleColor) { slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: "EAF2FF" }, line: { color: titleColor || C.boxBlue, width: 1.5 } }); slide.addShape(pres.ShapeType.rect, { x, y, w, h: 0.38, fill: { color: titleColor || C.boxBlue }, line: { color: titleColor || C.boxBlue, width: 0 } }); slide.addText(title, { x: x + 0.08, y, w: w - 0.16, h: 0.38, fontSize: 12, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); const items = bullets.map((b, i) => ({ text: b, options: { bullet: true, breakLine: i < bullets.length - 1, fontSize: 10.5, color: C.darkText, fontFace: "Calibri" } })); slide.addText(items, { x: x + 0.1, y: y + 0.42, w: w - 0.2, h: h - 0.5, valign: "top" }); } // ══════════════════════════════════════════════════════════════ // SLIDE 1 — TITLE SLIDE // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); // Full dark bg s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); // Red accent strip top s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.12, fill: { color: C.crimson } }); // Red accent strip bottom s.addShape(pres.ShapeType.rect, { x: 0, y: 5.5, w: "100%", h: 0.12, fill: { color: C.crimson } }); // Heart icon decoration (large circle) s.addShape(pres.ShapeType.ellipse, { x: 7.5, y: 0.5, w: 2.2, h: 2.2, fill: { color: C.crimson }, line: { color: C.crimson } }); s.addText("♥", { x: 7.5, y: 0.6, w: 2.2, h: 2.0, fontSize: 60, color: C.white, align: "center", valign: "middle" }); // Title s.addText("HEART FAILURE", { x: 0.5, y: 0.9, w: 6.8, h: 1.1, fontSize: 46, bold: true, color: C.white, charSpacing: 4, fontFace: "Calibri" }); s.addText("TREATMENT PLAN", { x: 0.5, y: 1.95, w: 6.8, h: 0.7, fontSize: 28, bold: false, color: C.gold, charSpacing: 2, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: 0.5, y: 2.7, w: 6.5, h: 0, line: { color: C.crimson, width: 2 } }); s.addText("A Comprehensive Clinical Overview for MBBS Final Year Students", { x: 0.5, y: 2.85, w: 9, h: 0.5, fontSize: 14, italic: true, color: C.grayLight, fontFace: "Calibri" }); s.addText([ { text: "Topics Covered: ", options: { bold: true, color: C.gold } }, { text: "Definition | Classification | Pathophysiology | Pharmacotherapy | Non-pharmacological | Devices | Special Cases", options: { color: C.grayLight } } ], { x: 0.5, y: 3.5, w: 9.2, h: 0.5, fontSize: 11, fontFace: "Calibri" }); s.addText("Based on ACC/AHA 2022 HF Guidelines & ESC 2021 Guidelines", { x: 0.5, y: 4.9, w: 9, h: 0.4, fontSize: 11, color: C.grayMid, fontFace: "Calibri", italic: true }); } // ══════════════════════════════════════════════════════════════ // SLIDE 2 — DEFINITION & EPIDEMIOLOGY // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Definition & Epidemiology"); s.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.9, w: 9.4, h: 1.0, fill: { color: C.navyMid }, line: { color: C.navy } }); s.addText([ { text: "Heart failure (HF) ", options: { bold: true, color: C.gold } }, { text: "is a complex clinical syndrome in which structural or functional cardiac impairment reduces the heart's ability to fill or eject blood, causing symptoms of dyspnea, fatigue, and fluid retention.", options: { color: C.white } } ], { x: 0.5, y: 0.92, w: 9.0, h: 0.95, fontSize: 13, fontFace: "Calibri", valign: "middle" }); // Epidemiology boxes const epiBullets = [ ["~64 million people globally affected", "Leading cause of hospitalization in >65 yrs", "~50% die within 5 years of diagnosis"], ["Prevalence: 1-2% in developed countries", "Annual incidence increasing with aging population", "Direct cost: USD 30 billion annually (USA)"], ["Most common causes: CAD (ischaemic), Hypertension, Cardiomyopathy, Valvular disease, Myocarditis", "Precipitants: Infection, Non-compliance, AF, Anaemia"] ]; const boxColors = [C.boxBlue, C.boxOrange, C.boxGreen]; const boxTitles = ["Global Burden", "Prevalence & Cost", "Aetiology"]; for (let i = 0; i < 3; i++) { addBox(s, boxTitles[i], epiBullets[i], 0.25 + i * 3.2, 2.05, 3.0, 2.85, boxColors[i]); } s.addText("Mnemonic: FAILURE — Fatigue, Activity limitation, Irregular heartbeat, Leg swelling, Unusual breathlessness, Reduced EF, Extra sounds (S3)", { x: 0.3, y: 5.1, w: 9.4, h: 0.4, fontSize: 10.5, color: C.crimson, italic: true, fontFace: "Calibri" }); } // ══════════════════════════════════════════════════════════════ // SLIDE 3 — CLASSIFICATION: ACC/AHA STAGES & NYHA // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Classification: ACC/AHA Stages & NYHA Functional Classes"); // ACC/AHA stages table const stages = [ { stage: "A", nyha: "Pre-HF", desc: "At-risk: HTN, DM, CAD\n(No structural disease)", mgmt: "Treat risk factors", color: C.greenSoft }, { stage: "B", nyha: "I", desc: "Structural disease\n(No symptoms)", mgmt: "ACEI/ARB + β-blocker", color: C.gold }, { stage: "C", nyha: "II / III", desc: "Structural disease\n+ Symptoms", mgmt: "Diuretic + ACEI/ARB/ARNI\n+ β-blocker + MRA + SGLT2i", color: C.crimsonSoft }, { stage: "D", nyha: "IV", desc: "Refractory HF\nSymptoms at rest", mgmt: "LVAD, Transplant\nPalliative care", color: C.boxRed }, ]; const stageX = [0.2, 2.6, 5.0, 7.4]; stages.forEach((st, i) => { const x = stageX[i]; s.addShape(pres.ShapeType.rect, { x, y: 0.85, w: 2.3, h: 4.55, fill: { color: "FDFEFE" }, line: { color: st.color, width: 2 } }); s.addShape(pres.ShapeType.rect, { x, y: 0.85, w: 2.3, h: 0.6, fill: { color: st.color } }); s.addText(`Stage ${st.stage}`, { x, y: 0.85, w: 2.3, h: 0.6, fontSize: 18, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); s.addText(`NYHA Class: ${st.nyha}`, { x: x + 0.1, y: 1.5, w: 2.1, h: 0.35, fontSize: 11, bold: true, color: st.color, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: x + 0.1, y: 1.87, w: 2.1, h: 0, line: { color: C.grayLight, width: 1 } }); s.addText(st.desc, { x: x + 0.1, y: 1.95, w: 2.1, h: 1.0, fontSize: 10.5, color: C.darkText, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: x + 0.1, y: 3.0, w: 2.1, h: 0, line: { color: C.grayLight, width: 1 } }); s.addText("Management:", { x: x + 0.1, y: 3.08, w: 2.1, h: 0.3, fontSize: 10, bold: true, color: C.grayMid, fontFace: "Calibri" }); s.addText(st.mgmt, { x: x + 0.1, y: 3.4, w: 2.1, h: 1.9, fontSize: 10, color: C.darkText, fontFace: "Calibri" }); }); // Arrow between stages for (let i = 0; i < 3; i++) { s.addText("→", { x: stageX[i] + 2.32, y: 2.8, w: 0.3, h: 0.4, fontSize: 18, color: C.grayMid, align: "center" }); } } // ══════════════════════════════════════════════════════════════ // SLIDE 4 — EF-BASED CLASSIFICATION // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "EF-Based Classification: HFrEF, HFmrEF, HFpEF"); const efTypes = [ { label: "HFrEF", efRange: "EF < 40%", subtitle: "Reduced EF (Systolic HF)", color: C.boxRed, patho: "Impaired systolic contractility\nDilated LV cavity\nReduced stroke volume", treatment: "Full GDMT: ARNI/ACEI + β-blocker\n+ MRA + SGLT2i + Diuretics", drugs: "Sacubitril/Valsartan, Carvedilol, Spironolactone, Dapagliflozin" }, { label: "HFmrEF", efRange: "EF 40–49%", subtitle: "Mildly Reduced EF", color: C.gold, patho: "Mixed systolic/diastolic dysfunction\nIntermediate phenotype\nOften ischaemic aetiology", treatment: "Consider GDMT agents\nDiuretics for congestion\nTreat underlying cause", drugs: "ACEI/ARB, β-blockers, SGLT2i (emerging evidence)" }, { label: "HFpEF", efRange: "EF ≥ 50%", subtitle: "Preserved EF (Diastolic HF)", color: C.boxGreen, patho: "Impaired ventricular relaxation\nStiff LV\nHigher filling pressures", treatment: "Treat comorbidities (HTN, AF, obesity)\nSGLT2i reduce hospitalizations", drugs: "SGLT2i (Empagliflozin, Dapagliflozin)\nDiuretics for symptoms" } ]; efTypes.forEach((ef, i) => { const x = 0.2 + i * 3.25; s.addShape(pres.ShapeType.rect, { x, y: 0.85, w: 3.05, h: 4.55, fill: { color: "FDFEFE" }, line: { color: ef.color, width: 2 } }); s.addShape(pres.ShapeType.rect, { x, y: 0.85, w: 3.05, h: 0.75, fill: { color: ef.color } }); s.addText(ef.label, { x, y: 0.87, w: 3.05, h: 0.38, fontSize: 20, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); s.addText(ef.efRange, { x, y: 1.22, w: 3.05, h: 0.35, fontSize: 12, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); s.addText(ef.subtitle, { x: x + 0.1, y: 1.65, w: 2.85, h: 0.35, fontSize: 10.5, bold: true, color: ef.color, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: x + 0.1, y: 2.05, w: 2.85, h: 0, line: { color: C.grayLight, width: 1 } }); s.addText("Pathophysiology:", { x: x + 0.1, y: 2.1, w: 2.85, h: 0.3, fontSize: 9.5, bold: true, color: C.grayMid, fontFace: "Calibri" }); s.addText(ef.patho, { x: x + 0.1, y: 2.42, w: 2.85, h: 0.85, fontSize: 10, color: C.darkText, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: x + 0.1, y: 3.32, w: 2.85, h: 0, line: { color: C.grayLight, width: 1 } }); s.addText("Treatment Strategy:", { x: x + 0.1, y: 3.37, w: 2.85, h: 0.3, fontSize: 9.5, bold: true, color: C.grayMid, fontFace: "Calibri" }); s.addText(ef.treatment, { x: x + 0.1, y: 3.7, w: 2.85, h: 0.75, fontSize: 10, color: C.darkText, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: x + 0.1, y: 4.5, w: 2.85, h: 0, line: { color: C.grayLight, width: 1 } }); s.addText(ef.drugs, { x: x + 0.1, y: 4.55, w: 2.85, h: 0.75, fontSize: 9.5, italic: true, color: ef.color, fontFace: "Calibri" }); }); } // ══════════════════════════════════════════════════════════════ // SLIDE 5 — PATHOPHYSIOLOGY // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.crimson } }); s.addText("Pathophysiology of Heart Failure", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); // Central cascade const steps = [ { label: "Cardiac Injury / Stress", detail: "(MI, HTN, Cardiomyopathy)", color: C.crimson, x: 3.8, y: 0.85 }, { label: "Reduced CO / Stretch", detail: "Decreased cardiac output", color: C.boxOrange, x: 3.8, y: 1.65 }, { label: "Neurohormonal Activation", detail: "RAAS + SNS + ADH + BNP", color: C.gold, x: 3.8, y: 2.45 }, { label: "Maladaptive Remodeling", detail: "Ventricular dilation, hypertrophy, fibrosis", color: C.boxBlue, x: 3.8, y: 3.25 }, { label: "Progressive HF & Death", detail: "SCD, pump failure", color: C.boxRed, x: 3.8, y: 4.05 }, ]; steps.forEach((st, i) => { s.addShape(pres.ShapeType.roundRect, { x: st.x, y: st.y, w: 4.2, h: 0.65, fill: { color: st.color }, rectRadius: 0.12, line: { color: st.color } }); s.addText(st.label, { x: st.x + 0.1, y: st.y + 0.02, w: 4.0, h: 0.35, fontSize: 12.5, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); s.addText(st.detail, { x: st.x + 0.1, y: st.y + 0.35, w: 4.0, h: 0.28, fontSize: 10, color: C.white, fontFace: "Calibri" }); if (i < steps.length - 1) { s.addText("▼", { x: st.x + 1.8, y: st.y + 0.65, w: 0.6, h: 0.35, fontSize: 16, color: C.grayLight, align: "center" }); } }); // Side panels addBox(s, "RAAS Activation", ["↑ Renin → AngII → Aldosterone", "Na+/H2O retention", "Vasoconstriction", "Myocardial fibrosis", "Hypertension ↑"], 0.15, 0.85, 3.45, 2.4, C.boxBlue); addBox(s, "SNS Activation", ["↑ NE → tachycardia", "↑ contractility (short-term)", "↑ afterload (long-term)", "β-receptor downregulation", "Arrhythmia risk ↑"], 0.15, 3.35, 3.45, 2.05, C.boxPurple); } // ══════════════════════════════════════════════════════════════ // SLIDE 6 — DIAGNOSIS // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Diagnosis of Heart Failure"); addBox(s, "Clinical Features", [ "SYMPTOMS: Dyspnea (exertional → rest), Orthopnea, PND, Fatigue, Leg swelling", "SIGNS: Raised JVP, S3 gallop, Pulmonary crepitations, Peripheral oedema, Displaced apex", "Reduced exercise tolerance, Cachexia in severe HF" ], 0.2, 0.9, 4.6, 2.1, C.boxBlue); addBox(s, "Investigations", [ "BNP >100 pg/mL or NT-proBNP >300 pg/mL (diagnosis)", "ECG: LVH, Q waves, LBBB, AF", "CXR: Cardiomegaly (CTR >0.5), Kerley B lines, Bat-wing opacity, Pleural effusion", "Echo: EF, wall motion, valves (KEY investigation)", "Bloods: FBC, U&E, LFT, TFT, Lipids, HbA1c" ], 5.0, 0.9, 4.7, 2.1, C.boxRed); addBox(s, "Framingham Criteria (2 Major OR 1 Major + 2 Minor)", [ "MAJOR: PND, Orthopnea, Raised JVP, S3 gallop, Cardiomegaly, Pulmonary oedema, Weight loss >4.5 kg in 5 days on Rx", "MINOR: Bilateral ankle oedema, Nocturnal cough, Dyspnoea on exertion, Hepatomegaly, Pleural effusion, Tachycardia (HR >120)" ], 0.2, 3.1, 4.6, 2.3, C.boxOrange); addBox(s, "Echocardiographic Assessment", [ "EF measurement (Biplane Simpson's method)", "Assess diastolic function: E/e' ratio, E/A ratio", "Wall motion abnormality → ischaemic HF", "Valvular pathology identification", "Estimated RVSP for pulmonary HTN", "Pericardial effusion" ], 5.0, 3.1, 4.7, 2.3, C.boxGreen); } // ══════════════════════════════════════════════════════════════ // SLIDE 7 — TREATMENT OVERVIEW (THE PILLARS) // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.crimson } }); s.addText("Treatment Pillars of Heart Failure", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); const pillars = [ { icon: "💊", title: "Pharmacotherapy", items: ["ACEi / ARB / ARNI", "Beta-Blockers", "MRA (Spironolactone)", "SGLT2 inhibitors", "Diuretics", "Digoxin (selected)"], color: C.crimsonSoft }, { icon: "🥗", title: "Non-Pharmacological", items: ["Salt restriction (<2g/day)", "Fluid restriction", "Weight monitoring", "Smoking cessation", "Exercise rehab (HF-ACTION)", "Cardiac rehab programme"], color: C.boxBlue }, { icon: "⚙️", title: "Device Therapy", items: ["ICD (SCD prevention)", "CRT (biventricular pacing)", "LVAD (bridge to Tx)", "Heart transplantation", "TAVI/surgical valve"], color: C.boxOrange }, { icon: "🏥", title: "Acute HF Management", items: ["Oxygen / NIV (CPAP)", "IV Furosemide", "IV Nitrates (vasodilators)", "Inotropes (dopamine, dobutamine)", "Morphine (cautious use)", "Treat precipitants"], color: C.boxGreen }, ]; pillars.forEach((p, i) => { const x = 0.2 + i * 2.42; s.addShape(pres.ShapeType.rect, { x, y: 0.88, w: 2.3, h: 4.5, fill: { color: C.navyMid }, line: { color: p.color, width: 2 } }); s.addShape(pres.ShapeType.rect, { x, y: 0.88, w: 2.3, h: 0.65, fill: { color: p.color } }); s.addText(p.icon + " " + p.title, { x: x + 0.06, y: 0.88, w: 2.18, h: 0.65, fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); const bullets = p.items.map((it, j) => ({ text: it, options: { bullet: true, breakLine: j < p.items.length - 1, fontSize: 10.5, color: C.offWhite, fontFace: "Calibri" } })); s.addText(bullets, { x: x + 0.1, y: 1.6, w: 2.1, h: 3.65, valign: "top" }); }); } // ══════════════════════════════════════════════════════════════ // SLIDE 8 — PHARMACOTHERAPY: GDMT OVERVIEW // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Guideline-Directed Medical Therapy (GDMT) for HFrEF"); // "Fantastic Four" label s.addShape(pres.ShapeType.rect, { x: 0.3, y: 0.85, w: 9.2, h: 0.4, fill: { color: C.navyMid } }); s.addText('The "Fantastic Four" — Cornerstone of HFrEF Treatment (Mortality Benefit)', { x: 0.3, y: 0.85, w: 9.2, h: 0.4, fontSize: 12, bold: true, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri" }); const gdmt = [ { class: "ARNI / ACEi / ARB", example: "Sacubitril/Valsartan\n(Entresto)", mechanism: "Blocks RAAS; ARNI also inhibits neprilysin → ↑ natriuretic peptides → vasodilation + natriuresis", mortality: "↓ Mortality by 20% (PARADIGM-HF)", dose: "Sacubitril/Val: 49/51mg BD\nEnalaprll: 2.5–20mg BD", cautions: "Avoid in pregnancy, bilateral RAS, hyperkalemia; 36h washout from ACEi before ARNI", color: C.boxBlue }, { class: "Beta-Blockers", example: "Carvedilol\nBisoprolol\nMetoprolol succinate", mechanism: "Blocks SNS; ↓ HR, ↓ remodeling, antiarrhythmic, ↑ EF", mortality: "↓ Mortality by ~34% (COPERNICUS, MERIT-HF)", dose: "Carvedilol: 3.125–25mg BD\nBisoprolol: 1.25–10mg OD", cautions: "Start low dose; avoid in acute decompensation, severe bradycardia, severe bronchospasm", color: C.boxRed }, { class: "MRA (Aldosterone Antagonist)", example: "Spironolactone\nEplerenone", mechanism: "Blocks aldosterone → ↓ Na/H2O retention, ↓ fibrosis, ↓ myocardial remodeling", mortality: "↓ Mortality 30% (RALES), ↓ SCD", dose: "Spironolactone: 25–50mg OD\nEplerenone: 25–50mg OD", cautions: "Monitor K+ (hyperkalemia risk); avoid if K+>5 or eGFR<30. Gynaecomastia with spironolactone", color: C.boxOrange }, { class: "SGLT2 Inhibitors", example: "Dapagliflozin\nEmpagliflozin", mechanism: "Osmotic diuresis; metabolic/cardiac protective effects independent of glucose lowering", mortality: "↓ CV death/HHF by 25% (DAPA-HF, EMPEROR-Reduced)", dose: "Dapagliflozin: 10mg OD\nEmpagliflozin: 10mg OD", cautions: "DKA risk (rare); genital mycotic infections; UTI; hold peri-operatively; volume depletion", color: C.boxGreen }, ]; gdmt.forEach((d, i) => { const x = 0.2 + i * 2.42; const y = 1.35; s.addShape(pres.ShapeType.rect, { x, y, w: 2.3, h: 4.05, fill: { color: "FDFEFE" }, line: { color: d.color, width: 1.5 } }); s.addShape(pres.ShapeType.rect, { x, y, w: 2.3, h: 0.55, fill: { color: d.color } }); s.addText(d.class, { x: x + 0.05, y: y, w: 2.2, h: 0.55, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); s.addText(d.example, { x: x + 0.08, y: y + 0.58, w: 2.14, h: 0.45, fontSize: 10, bold: true, color: d.color, fontFace: "Calibri" }); s.addText("Mechanism: " + d.mechanism, { x: x + 0.08, y: y + 1.05, w: 2.14, h: 0.85, fontSize: 9, color: C.darkText, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: x + 0.08, y: y + 1.92, w: 2.1, h: 0, line: { color: C.grayLight, width: 0.8 } }); s.addText(d.mortality, { x: x + 0.08, y: y + 1.97, w: 2.14, h: 0.35, fontSize: 9.5, bold: true, color: C.greenSoft, fontFace: "Calibri" }); s.addText("Dose: " + d.dose, { x: x + 0.08, y: y + 2.34, w: 2.14, h: 0.65, fontSize: 9, color: C.darkText, fontFace: "Calibri" }); s.addText("Cautions: " + d.cautions, { x: x + 0.08, y: y + 3.0, w: 2.14, h: 0.95, fontSize: 8.5, italic: true, color: C.boxRed, fontFace: "Calibri" }); }); } // ══════════════════════════════════════════════════════════════ // SLIDE 9 — DIURETICS & DIGOXIN // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Diuretics, Digoxin & Vasodilators in HF"); addBox(s, "Loop Diuretics (Symptom Relief - Decongestion)", [ "Furosemide: 20–80 mg OD/BD (oral or IV in acute HF)", "Bumetanide: 0.5–2 mg OD (more bioavailable in oedema)", "Torasemide: 5–20 mg OD (better oral bioavailability)", "Mechanism: Inhibit Na+/K+/2Cl- cotransporter in thick ascending LOH", "Monitor: K+, Na+, Creatinine, Urine output, Daily weight", "Caution: Hypokalemia, hyponatraemia, volume depletion, ototoxicity (high IV doses)" ], 0.2, 0.9, 4.6, 2.5, C.boxBlue); addBox(s, "Thiazides & Combination Diuresis", [ "Metolazone or Bendroflumethiazide - add-on for diuretic resistance", "Combination: Loop + Thiazide = 'Sequential nephron blockade'", "Only under close electrolyte monitoring (aggressive)", "Spironolactone (MRA): also acts as diuretic + neurohormonal blocker", "Tolvaptan (V2-receptor antagonist): for hyponatraemia in HF" ], 5.0, 0.9, 4.7, 2.5, C.boxPurple); addBox(s, "Digoxin", [ "Mechanism: Inhibits Na+/K+-ATPase → ↑ intracellular Ca++ → +ve inotropy", "Slows ventricular rate in AF via vagotonic effect on AV node", "Indication: Symptomatic HFrEF with persistent AF or sinus rhythm (symptom control only)", "Dose: 62.5–250 mcg/day (renally adjusted); Target level 0.5–0.9 ng/mL", "Toxicity: N/V, visual (yellow/green halos), bradycardia, AV block, arrhythmias", "Toxicity precipitated by: Hypokalemia, Hypomagnesemia, Hypercalcemia, Renal impairment" ], 0.2, 3.5, 4.6, 2.0, C.boxOrange); addBox(s, "Vasodilators (Selected Populations)", [ "Hydralazine + Isosorbide Dinitrate: For Black African patients (A-HeFT trial)", "Used when ACEI/ARB/ARNI not tolerated (e.g. angioedema, severe CKD)", "IV Nitrates: GTN infusion in acute HF with hypertension", "Nesiritide (BNP analogue): IV vasodilator; does not improve mortality", "Ivabradine: For HFrEF, sinus rhythm, HR ≥70 bpm on max BB (SHIFT trial)" ], 5.0, 3.5, 4.7, 2.0, C.boxGreen); } // ══════════════════════════════════════════════════════════════ // SLIDE 10 — SACUBITRIL/VALSARTAN (ARNI) DEEP DIVE // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "ARNI: Sacubitril/Valsartan (Entresto) — Landmark Drug in HFrEF"); // Key info box s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.85, w: 9.5, h: 0.65, fill: { color: C.navyMid } }); s.addText("PARADIGM-HF Trial: Sacubitril/Valsartan reduced CV death by 20% and HHF by 21% vs Enalapril — STOPPED EARLY due to overwhelming benefit", { x: 0.2, y: 0.85, w: 9.5, h: 0.65, fontSize: 12, bold: true, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri" }); addBox(s, "Mechanism of Action", [ "Sacubitril = Neprilysin inhibitor → Prevents breakdown of BNP, ANP, CNP", "↑ Natriuretic peptides → vasodilation, natriuresis, anti-fibrotic", "Valsartan = ARB → blocks AT1 receptor → prevents RAAS activation", "Combined: Offload preload + afterload AND block RAAS" ], 0.2, 1.65, 4.6, 1.9, C.boxBlue); addBox(s, "Clinical Indications", [ "HFrEF (EF <40%) with persistent symptoms (NYHA II-IV)", "Already on ACEI/ARB: Switch to ARNI (superior)", "ACC/AHA: Class I recommendation (Level of Evidence B-R)", "MUST switch from ACEi → ARNI with 36-hour washout (angioedema risk)" ], 5.0, 1.65, 4.7, 1.9, C.boxRed); addBox(s, "Dosing", [ "Start: 24/26 mg twice daily", "Target: 97/103 mg twice daily", "Up-titrate every 2–4 weeks as tolerated", "Reduce initial dose if: eGFR<60, K+>5, SBP<100", "Monitor: BP, K+, Renal function, Angioedema" ], 0.2, 3.65, 4.6, 1.75, C.boxGreen); addBox(s, "Contraindications & Cautions", [ "Pregnancy (teratogenic) — ABSOLUTE CI", "History of angioedema with ACEI", "Concomitant ACEi use within 36 hours", "Severe hepatic impairment", "eGFR < 30 ml/min (relative CI)", "SBP < 100 mmHg (start cautiously)" ], 5.0, 3.65, 4.7, 1.75, C.boxOrange); } // ══════════════════════════════════════════════════════════════ // SLIDE 11 — SGLT2 INHIBITORS IN HF // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.crimson } }); s.addText("SGLT2 Inhibitors in Heart Failure — A Modern Breakthrough", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 21, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); // Trial results s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.88, w: 4.6, h: 2.2, fill: { color: C.navyMid }, line: { color: C.greenSoft, width: 2 } }); s.addText("DAPA-HF Trial (Dapagliflozin)", { x: 0.3, y: 0.92, w: 4.4, h: 0.35, fontSize: 13, bold: true, color: C.greenSoft, fontFace: "Calibri" }); const dapaItems = [ "HFrEF (EF<40%) patients — diabetic AND non-diabetic", "↓ Worsening HF or CV death by 26% (RRR)", "NNT = 21 to prevent one primary outcome", "Benefit seen regardless of T2DM status", "Now licensed for HFrEF (10mg OD)" ]; s.addText(dapaItems.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < dapaItems.length - 1, fontSize: 10.5, color: C.offWhite, fontFace: "Calibri" } })), { x: 0.3, y: 1.32, w: 4.4, h: 1.7, valign: "top" }); s.addShape(pres.ShapeType.rect, { x: 5.1, y: 0.88, w: 4.6, h: 2.2, fill: { color: C.navyMid }, line: { color: C.gold, width: 2 } }); s.addText("EMPEROR-Reduced (Empagliflozin)", { x: 5.2, y: 0.92, w: 4.4, h: 0.35, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" }); const emperItems = [ "HFrEF patients (EF<40%) — EMPEROR-Reduced", "↓ CV death/worsening HF by 25% (HR 0.75)", "EMPEROR-Preserved: First drug to reduce hospitalisation in HFpEF", "Licensed for HFrEF and HFpEF (10mg OD)", "FDA approved for both EF categories" ]; s.addText(emperItems.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < emperItems.length - 1, fontSize: 10.5, color: C.offWhite, fontFace: "Calibri" } })), { x: 5.2, y: 1.32, w: 4.4, h: 1.7, valign: "top" }); addBox(s, "Mechanisms of Cardioprotection", [ "Osmotic diuresis → ↓ preload (fluid/Na+ excretion)", "↓ Ventricular wall stress and myocardial oxygen demand", "Ketone body utilization by the heart (metabolic shift)", "Direct anti-inflammatory and anti-fibrotic effects", "↓ Uric acid, ↓ sympathetic activation" ], 0.2, 3.2, 4.6, 2.2, C.boxBlue); addBox(s, "Side Effects & Monitoring", [ "Genital mycotic infections (most common) — counsel patients", "Urinary frequency / UTI — monitor symptoms", "Euglycaemic DKA (rare, especially T1DM) — avoid in T1DM", "Volume depletion — caution with diuretics", "Hold 3 days before surgery (DKA risk)", "NOT recommended in eGFR < 20 ml/min" ], 5.1, 3.2, 4.6, 2.2, C.boxOrange); } // ══════════════════════════════════════════════════════════════ // SLIDE 12 — NON-PHARMACOLOGICAL TREATMENT // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Non-Pharmacological Management"); const items = [ { icon: "🧂", title: "Dietary Sodium", detail: "Restrict to <2g/day of sodium (5g NaCl)\nAvoid processed foods, canned products\nDiscuss with dietitian", color: C.boxBlue }, { icon: "💧", title: "Fluid Restriction", detail: "Restrict to 1.5–2 L/day in advanced HF\nMonitor daily fluid intake\nAvoid excessive fluid in HFpEF", color: C.boxRed }, { icon: "⚖️", title: "Weight Monitoring", detail: "Daily morning weight (after toileting, before eating)\nAlert if weight ↑ >2 kg in 3 days\nIndicator of fluid retention", color: C.boxOrange }, { icon: "🚭", title: "Smoking Cessation", detail: "Major independent risk factor for CAD\nNRT, Bupropion, Varenicline supported\nCardiac benefit within 1 year", color: C.boxPurple }, { icon: "🏃", title: "Exercise Rehab", detail: "HF-ACTION trial: Supervised exercise training\n↓ HF hospitalizations, ↑ QoL\nStart low-moderate intensity (NYHA I–III)", color: C.greenSoft }, { icon: "🍺", title: "Alcohol Restriction", detail: "Alcoholic cardiomyopathy: strict abstinence\nGeneral HF: limit to <14 units/week\nCan partially reverse with abstinence", color: C.gold }, ]; const cols = 3, rows = 2; const boxW = 3.1, boxH = 1.85; const startX = 0.15, startY = 0.9; items.forEach((item, i) => { const row = Math.floor(i / cols); const col = i % cols; const x = startX + col * 3.25; const y = startY + row * 2.0; s.addShape(pres.ShapeType.rect, { x, y, w: boxW, h: boxH, fill: { color: "FDFEFE" }, line: { color: item.color, width: 1.5 } }); s.addShape(pres.ShapeType.rect, { x, y, w: boxW, h: 0.38, fill: { color: item.color } }); s.addText(item.icon + " " + item.title, { x: x + 0.08, y, w: boxW - 0.16, h: 0.38, fontSize: 12, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); s.addText(item.detail, { x: x + 0.1, y: y + 0.42, w: boxW - 0.2, h: boxH - 0.5, fontSize: 10, color: C.darkText, fontFace: "Calibri" }); }); s.addShape(pres.ShapeType.rect, { x: 0.15, y: 4.95, w: 9.7, h: 0.45, fill: { color: C.navyMid } }); s.addText("Vaccination: Annual influenza + pneumococcal vaccines recommended in all HF patients to reduce hospitalization risk", { x: 0.25, y: 4.95, w: 9.5, h: 0.45, fontSize: 11, color: C.gold, valign: "middle", fontFace: "Calibri" }); } // ══════════════════════════════════════════════════════════════ // SLIDE 13 — DEVICE THERAPY // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Device Therapy in Heart Failure"); addBox(s, "ICD — Implantable Cardioverter-Defibrillator", [ "Indication: EF ≤35% on GDMT for ≥3 months, NYHA II–III, life expectancy >1 year", "Primary prevention of sudden cardiac death (SCD)", "Delivers electrical shock to terminate VF/VT", "Also provides overdrive pacing", "Studies: MADIT-II, SCD-HeFT — ↓ mortality by 23%" ], 0.2, 0.9, 4.6, 2.1, C.boxRed); addBox(s, "CRT — Cardiac Resynchronization Therapy", [ "Indication: EF ≤35% + LBBB (QRS ≥150ms) + NYHA II–IV on GDMT", "Biventricular pacing → resynchronizes LV-RV contraction", "↑ EF, ↓ HF symptoms, ↑ exercise tolerance", "CRT-D (combined CRT + ICD) preferred in eligible patients", "Studies: CARE-HF, COMPANION — significant mortality benefit" ], 5.0, 0.9, 4.7, 2.1, C.boxBlue); addBox(s, "LVAD — Left Ventricular Assist Device", [ "Mechanical pump implanted to assist LV ejection", "Uses: Bridge to transplant (BTT), Destination therapy, Bridge to recovery", "HeartMate 3 (continuous flow) — current standard", "MOMENTUM 3 trial: ↓ stroke, pump thrombosis vs older devices", "Complications: Stroke, Bleeding, Infection, Device malfunction", "Requires anticoagulation (Warfarin + Aspirin)" ], 0.2, 3.1, 4.6, 2.4, C.boxOrange); addBox(s, "Heart Transplantation", [ "Gold standard for end-stage HFrEF (Stage D)", "Indication: NYHA IV refractory to all therapy", "5-year survival: ~75%; median survival >13 years", "Contraindications: Active infection, malignancy, severe PHTN, age >70, BMI>35", "Immunosuppression: Cyclosporine/Tacrolimus + MMF + Steroids", "Complications: Rejection, infection, coronary allograft vasculopathy" ], 5.0, 3.1, 4.7, 2.4, C.boxPurple); } // ══════════════════════════════════════════════════════════════ // SLIDE 14 — ACUTE HF MANAGEMENT // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.crimson } }); s.addText("Acute Decompensated Heart Failure (ADHF) — Emergency Management", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 20, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); // LMNOP mnemonic s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.9, w: 5.0, h: 0.4, fill: { color: C.crimson } }); s.addText("LMNOP Mnemonic for Acute HF", { x: 0.2, y: 0.9, w: 5.0, h: 0.4, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); const lmnop = [ ["L", "Lasix (Furosemide)", "IV 40–80 mg bolus; target urine output 0.5–1 mL/kg/hr", C.crimsonSoft], ["M", "Morphine", "2–4 mg IV (cautious — may increase mortality; reduces anxiety)", C.boxBlue], ["N", "Nitrates", "GTN spray/infusion (if SBP >90); vasodilator, ↓ preload", C.boxOrange], ["O", "Oxygen / NIV", "Target SpO2 >95%; CPAP preferred in pulmonary oedema", C.greenSoft], ["P", "Position", "Sit upright (45° or legs dependent); ↓ venous return", C.boxPurple], ]; lmnop.forEach((l, i) => { s.addShape(pres.ShapeType.rect, { x: 0.2, y: 1.35 + i * 0.72, w: 5.0, h: 0.68, fill: { color: C.navyMid }, line: { color: l[3], width: 1 } }); s.addShape(pres.ShapeType.ellipse, { x: 0.25, y: 1.38 + i * 0.72, w: 0.5, h: 0.5, fill: { color: l[3] } }); s.addText(l[0], { x: 0.25, y: 1.38 + i * 0.72, w: 0.5, h: 0.5, fontSize: 16, bold: true, color: C.white, align: "center", valign: "middle" }); s.addText(l[1], { x: 0.85, y: 1.38 + i * 0.72, w: 2.2, h: 0.28, fontSize: 11, bold: true, color: l[3], fontFace: "Calibri" }); s.addText(l[2], { x: 0.85, y: 1.65 + i * 0.72, w: 4.25, h: 0.3, fontSize: 9.5, color: C.offWhite, fontFace: "Calibri" }); }); // Right panel — classification and inotropes addBox(s, "AHF Phenotypes & Initial Approach", [ "WARM & WET (most common): Diuretics, vasodilators", "COLD & WET (cardiogenic shock): Inotropes + vasopressors", "WARM & DRY (compensated): Optimise oral medications", "COLD & DRY: Cautious fluid challenge; consider LVAD/transplant", "BP guide: HTN AHF → nitrates; Hypotensive → inotropes" ], 5.4, 0.9, 4.4, 2.25, C.boxBlue); addBox(s, "Inotropes & Vasopressors (Cardiogenic Shock)", [ "Dobutamine: 2–20 mcg/kg/min IV — β1 agonist, ↑ contractility", "Dopamine: Low dose (1–5 mcg/kg/min) → renal vasodilatation; High (>10) → vasopressor", "Noradrenaline: For vasodilatory shock component", "Milrinone: PDE3 inhibitor — ↑ cAMP → +ve inotropy (avoid in CKD)", "Levosimendan: Ca2+ sensitizer — +ve inotropy without ↑ O2 demand" ], 5.4, 3.25, 4.4, 2.0, C.boxRed); } // ══════════════════════════════════════════════════════════════ // SLIDE 15 — HFpEF MANAGEMENT // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "HFpEF (Heart Failure with Preserved EF) — Management"); s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.88, w: 9.5, h: 0.55, fill: { color: C.navyMid } }); s.addText("HFpEF (EF ≥50%) represents ~50% of all HF cases — NO drug has shown clear mortality benefit EXCEPT SGLT2i", { x: 0.2, y: 0.88, w: 9.5, h: 0.55, fontSize: 12.5, bold: true, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri" }); addBox(s, "Treat Comorbidities (Priority)", [ "Hypertension: ACEi/ARB, CCBs, MRAs — aggressive BP control", "Atrial fibrillation: Rate control (BB, digoxin) or rhythm control", "Diabetes: SGLT2i (empagliflozin) reduces hospitalizations", "Obesity: Weight loss significantly ↑ exercise capacity", "Coronary artery disease: Revascularization if ischaemia present", "Sleep apnoea: CPAP therapy improves diastolic function" ], 0.2, 1.55, 4.6, 2.8, C.boxBlue); addBox(s, "Symptomatic Treatment", [ "Diuretics: For fluid overload / congestion symptoms (carefully — preload dependent)", "Avoid excessive diuresis → worsens CO in stiff, non-dilated LV", "Spironolactone: TOPCAT trial — borderline; may reduce HHF", "Nitrates: May worsen symptoms in HFpEF (exercise intolerance trial)", "SGLT2i (Empagliflozin): EMPEROR-Preserved — significant ↓ HHF" ], 5.0, 1.55, 4.7, 2.8, C.boxOrange); addBox(s, "Emerging / Investigational", [ "Finerenone (non-steroidal MRA): FINEARTS-HF trial — promising", "GLP-1 agonists (Semaglutide): STEP-HFpEF trial — ↑ exercise capacity, ↓ weight", "Sacubitril/Valsartan: PARAGON-HF — benefit in EF 45–55%", "Sodium restriction + exercise remains cornerstone" ], 0.2, 4.45, 9.5, 1.0, C.boxGreen); } // ══════════════════════════════════════════════════════════════ // SLIDE 16 — CARDIOGENIC SHOCK // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.crimson } }); s.addText("Cardiogenic Shock — Recognition & Management", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); addBox(s, "Definition & Diagnostic Criteria", [ "SBP <90 mmHg for >30 min OR vasopressor dependent", "Signs of hypoperfusion: Cool clammy skin, confusion, oliguria (UO <0.5 mL/kg/hr)", "Elevated LVEDP / PCWP >18 mmHg", "Cardiac Index <2.2 L/min/m² on Swan-Ganz catheter", "Elevated lactate >2 mmol/L (tissue hypoperfusion)" ], 0.2, 0.9, 4.6, 2.1, C.boxRed); addBox(s, "Causes (MNEMONIC: CHAMP)", [ "C — CAD / Acute MI (most common, ~80%)", "H — Hypertrophic cardiomyopathy", "A — Arrhythmia", "M — Mechanical complication (VSD, acute MR, free wall rupture)", "P — Pulmonary embolism / Pericardial tamponade" ], 5.0, 0.9, 4.7, 2.1, C.boxOrange); addBox(s, "Stepwise Management", [ "1. Airway & O2: Intubation if GCS <8 or SpO2 <90% despite NIV", "2. IV Access: Large-bore x2 + arterial line + CVP monitoring", "3. IV Fluids: Cautious 250 mL crystalloid if not fluid-overloaded", "4. Vasopressors: Noradrenaline (first line) to maintain MAP >65", "5. Inotropes: Dobutamine or Milrinone for low CO", "6. Revascularization: Emergency PCI for ACS-related shock (SHOCK trial)", "7. MCS: IABP, Impella, VA-ECMO in refractory cases" ], 0.2, 3.1, 9.5, 2.3, C.boxBlue); } // ══════════════════════════════════════════════════════════════ // SLIDE 17 — RIGHT HEART FAILURE // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Right Heart Failure — Aetiology, Features & Management"); addBox(s, "Causes of RHF", [ "Left HF with pulmonary hypertension (most common)", "Pulmonary arterial hypertension (PAH)", "Massive pulmonary embolism", "Cor pulmonale (chronic lung disease — COPD, ILD)", "RV infarction (inferior STEMI)", "Tricuspid/pulmonary valve disease", "ARVC (arrhythmogenic right ventricular cardiomyopathy)" ], 0.2, 0.9, 3.0, 3.5, C.boxBlue); addBox(s, "Clinical Features", [ "Raised JVP with prominent 'v' waves", "Peripheral oedema (pitting) bilateral", "Hepatomegaly → Ascites (cardiac cirrhosis)", "Right-sided S3 gallop", "Parasternal heave (RV hypertrophy)", "Kussmaul's sign (JVP ↑ on inspiration)", "Symptoms: fatigue, exertional dyspnoea, abdominal distension" ], 3.35, 0.9, 3.3, 3.5, C.boxOrange); addBox(s, "Management", [ "Treat underlying cause (PAH, PE, COPD)", "Diuretics: Cautious — avoid over-diuresis (worsens CO)", "Avoid excessive fluid removal in RV infarction (preload dependent)", "Pulmonary vasodilators in PAH: Sildenafil, Bosentan, Prostanoids", "RV infarction: IV fluids (cautious), avoid nitrates", "Anticoagulation if PE cause", "Advanced: Balloon septostomy, PAH-specific therapy" ], 6.8, 0.9, 2.95, 3.5, C.boxGreen); s.addShape(pres.ShapeType.rect, { x: 0.2, y: 4.5, w: 9.5, h: 0.9, fill: { color: C.navyMid } }); s.addText("KEY EXAM POINT: In RV infarction — give FLUIDS, avoid diuretics & nitrates (RV is preload dependent). JVP elevated but lungs are CLEAR.", { x: 0.3, y: 4.5, w: 9.3, h: 0.9, fontSize: 12, bold: true, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri" }); } // ══════════════════════════════════════════════════════════════ // SLIDE 18 — CLINICAL CASE 1 // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.navyMid } }); s.addText("CLINICAL CASE 1 — Acute Decompensated HF", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: C.gold, valign: "middle", fontFace: "Calibri" }); s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.9, w: 9.5, h: 1.85, fill: { color: "EAF2FF" }, line: { color: C.boxBlue, width: 1.5 } }); s.addText("SCENARIO:", { x: 0.35, y: 0.95, w: 1.5, h: 0.3, fontSize: 11, bold: true, color: C.boxBlue, fontFace: "Calibri" }); s.addText("A 68-year-old male with known ischaemic cardiomyopathy (EF 30%) and T2DM presents to A&E with sudden-onset severe dyspnoea, orthopnoea and leg swelling for 3 days. He stopped his medications 2 weeks ago. On examination: RR 28/min, SpO2 88% on air, BP 160/100, HR 110 irregular. JVP raised 5 cm, bilateral crepitations, pitting oedema to knees. CXR: Cardiomegaly, bilateral pulmonary oedema. BNP: 2400 pg/mL. Echo: EF 28%, dilated LV.", { x: 0.35, y: 1.28, w: 9.2, h: 1.4, fontSize: 11, color: C.darkText, fontFace: "Calibri" }); addBox(s, "Immediate Management (First 2 Hours)", [ "Sit upright (45°), high-flow O2, CPAP/BiPAP (SpO2 target >95%)", "IV Furosemide 80mg stat (double home dose if known diuretic user)", "IV GTN infusion if SBP >90 mmHg (titrate to symptom relief)", "Continuous monitoring: ECG, SpO2, hourly UO via catheter", "Treat AF: Rate control (digoxin or BB when stable)", "Bloods: U&E, FBC, Troponin, BNP, Glucose, ABG" ], 0.2, 2.85, 4.6, 2.3, C.boxRed); addBox(s, "Ongoing & Discharge Plan", [ "Resume GDMT: ARNI (sacubitril/valsartan), carvedilol, spironolactone", "Add Dapagliflozin 10mg OD (SGLT2i — dual benefit in T2DM + HF)", "Oral furosemide dose titration (target: dry weight, no oedema)", "HF nurse specialist referral + medication education", "Anticoagulation for AF: CHA₂DS₂-VASc ≥2 → DOAC", "Device assessment: EF<35% → ICD ± CRT in 3 months on GDMT" ], 5.0, 2.85, 4.7, 2.3, C.boxGreen); } // ══════════════════════════════════════════════════════════════ // SLIDE 19 — CLINICAL CASE 2 // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.navyMid } }); s.addText("CLINICAL CASE 2 — New-Onset HFpEF", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: C.gold, valign: "middle", fontFace: "Calibri" }); s.addShape(pres.ShapeType.rect, { x: 0.2, y: 0.9, w: 9.5, h: 1.85, fill: { color: "EAF2FF" }, line: { color: C.boxBlue, width: 1.5 } }); s.addText("SCENARIO:", { x: 0.35, y: 0.95, w: 1.5, h: 0.3, fontSize: 11, bold: true, color: C.boxBlue, fontFace: "Calibri" }); s.addText("A 72-year-old female with hypertension, atrial fibrillation, and obesity (BMI 38) presents with progressive breathlessness on exertion and bilateral ankle swelling over 6 weeks. She denies orthopnoea or PND. On exam: BP 165/95, HR 85 irregular, JVP mildly elevated, bilateral ankle oedema, no pulmonary crepitations. Echo: Normal EF (EF 60%), grade 2 diastolic dysfunction, E/e' ratio = 18, mild LA dilation. BNP: 320 pg/mL. ECG: Atrial fibrillation.", { x: 0.35, y: 1.28, w: 9.2, h: 1.4, fontSize: 11, color: C.darkText, fontFace: "Calibri" }); addBox(s, "Diagnosis & Investigations", [ "HFpEF (EF ≥50% + diastolic dysfunction + elevated BNP)", "Echocardiographic criteria: E/e' >15 = elevated filling pressures", "HFA-PEFF Score: Clinical + functional + morphological assessment", "Exclude: Ischaemia (coronary CT/angiogram), cardiac amyloid (SPECT, biopsy)", "Cardiac MRI: Gold standard for morphology and infiltrative diseases" ], 0.2, 2.85, 4.6, 2.1, C.boxOrange); addBox(s, "Management Plan", [ "Diuretics: Furosemide 40mg OD for oedema (cautious)", "BP Control: ARB (candesartan) or ACEi — target <130/80", "AF Rate Control: Bisoprolol + Digoxin (HR target 60–90 bpm)", "SGLT2i: Empagliflozin 10mg OD (EMPEROR-Preserved evidence)", "Lifestyle: Salt restriction, weight loss target 10%, exercise rehab", "DOAC for AF: Apixaban 5mg BD (CHA₂DS₂-VASc 4 = high risk)" ], 5.0, 2.85, 4.7, 2.1, C.boxGreen); } // ══════════════════════════════════════════════════════════════ // SLIDE 20 — MONITORING & FOLLOW-UP // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Monitoring, Follow-Up & Prognostic Markers"); addBox(s, "Routine Monitoring Parameters", [ "Symptoms: NYHA class, dyspnoea score, exercise tolerance", "Fluid: Daily weight, urine output, peripheral oedema", "Vitals: BP, HR, RR, SpO2", "Bloods: U&E (K+, Na+, Creatinine) — 1–2 weeks after any dose change", "BNP/NT-proBNP: Serial measurements to guide therapy titration", "Renal function: ACEi/ARB/MRA can ↓ GFR — acceptable if <25% rise" ], 0.2, 0.9, 4.6, 2.5, C.boxBlue); addBox(s, "Echocardiographic Follow-Up", [ "Repeat echo at 3–6 months after initiating GDMT", "If EF improves to >40% on GDMT — consider LVEF recovery (HFimprovedEF)", "Caution: Do NOT stop GDMT even if EF normalizes (TRED-HF trial: relapse risk)", "Annual echo in stable HF; more frequent in unstable or device patients", "ICD/CRT programming review every 3–6 months" ], 5.0, 0.9, 4.7, 2.5, C.boxRed); addBox(s, "Poor Prognostic Markers", [ "Very low EF (<20%), NYHA IV, renal impairment", "Persistently elevated BNP despite GDMT", "Recurrent hospitalizations (>2/year)", "Hyponatraemia (Na+ <135 mEq/L) — sign of advanced HF", "Cardiac cachexia, low BMI", "Functional MR, Wide QRS without CRT, AF" ], 0.2, 3.5, 4.6, 2.0, C.boxOrange); addBox(s, "Referral Criteria", [ "Cardiology referral: All newly diagnosed HF", "Advanced HF team: Stage D, LVAD candidate, transplant evaluation", "ICD/CRT: EF ≤35% after ≥3 months optimal GDMT", "Palliative care: Stage D refractory, poor prognosis, poor QoL", "HF nurse specialist: All patients for education & self-management" ], 5.0, 3.5, 4.7, 2.0, C.boxPurple); } // ══════════════════════════════════════════════════════════════ // SLIDE 21 — SPECIAL POPULATIONS // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "Heart Failure in Special Populations"); const pops = [ { title: "HF in Pregnancy (PPCM)", color: C.boxRed, items: ["Peripartum cardiomyopathy: EF <45% in last month of pregnancy/5 months postpartum", "Avoid: ACEi, ARBs, ARNI, MRAs, SGLT2i (teratogenic)", "Safe: Hydralazine + Nitrates (vasodilators), Furosemide, BB (labetalol)", "Bromocriptine: May ↑ recovery (inhibits prolactin cleavage)", "Prognosis: 50% recover EF fully"] }, { title: "HF in CKD", color: C.boxBlue, items: ["Major comorbidity: ↑ mortality risk", "ACEi/ARB: Acceptable up to eGFR 30; monitor K+ closely", "SGLT2i: Avoid if eGFR <20 (dapagliflozin) / <25 (empagliflozin)", "MRA: Avoid if eGFR <30 or K+ >5.0 mEq/L", "Digoxin: Renally dosed; narrow TI — drug levels essential"] }, { title: "HF in Elderly", color: C.boxOrange, items: ["Polypharmacy risk: Review all drugs for interactions", "HFpEF predominates in elderly women", "Diuretics: Higher risk of falls, dehydration, AKI", "Start doses very low; up-titrate slowly", "Cognitive function and ADL: important for compliance", "Falls risk with β-blockers (bradycardia, dizziness)"] }, { title: "HF with AF", color: C.boxPurple, items: ["AF present in 30-40% of HF patients", "Rate control preferred unless symptoms dictate rhythm control", "Rate targets: resting HR 60-100 bpm", "Anticoagulation: DOAC (apixaban/rivaroxaban) preferred over warfarin", "Ablation: CASTLE-AF trial showed ↑ EF, ↓ mortality post-ablation", "Digoxin: Add for rate control if β-blocker inadequate"] }, ]; pops.forEach((p, i) => { const row = Math.floor(i / 2); const col = i % 2; const x = 0.2 + col * 4.9; const y = 0.9 + row * 2.35; addBox(s, p.title, p.items, x, y, 4.6, 2.2, p.color); }); } // ══════════════════════════════════════════════════════════════ // SLIDE 22 — KEY CLINICAL TRIALS // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.75, fill: { color: C.crimson } }); s.addText("Landmark Clinical Trials in Heart Failure", { x: 0.3, y: 0, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: C.white, valign: "middle", fontFace: "Calibri" }); const trials = [ { name: "SOLVD (1991)", drug: "Enalapril (ACEi)", finding: "↓ Mortality 16%, ↓ HHF 26% vs placebo in HFrEF", color: C.boxBlue }, { name: "MERIT-HF (1999)", drug: "Metoprolol succinate (BB)", finding: "↓ All-cause mortality 34% vs placebo in HFrEF", color: C.boxOrange }, { name: "RALES (1999)", drug: "Spironolactone (MRA)", finding: "↓ Mortality 30%, ↓ SCD in severe HFrEF", color: C.boxPurple }, { name: "COPERNICUS (2001)", drug: "Carvedilol (BB)", finding: "↓ All-cause mortality 35% in severe HFrEF (EF<25%)", color: C.boxRed }, { name: "PARADIGM-HF (2014)", drug: "Sacubitril/Valsartan (ARNI)", finding: "↓ CV death 20%, ↓ HHF 21% vs Enalapril — STOPPED EARLY", color: C.gold }, { name: "DAPA-HF (2019)", drug: "Dapagliflozin (SGLT2i)", finding: "↓ Worsening HF/CV death 26% (diabetic + non-diabetic HFrEF)", color: C.greenSoft }, { name: "EMPEROR-Reduced (2020)", drug: "Empagliflozin (SGLT2i)", finding: "↓ CV death/HHF 25% in HFrEF", color: C.boxGreen }, { name: "EMPEROR-Preserved (2021)", drug: "Empagliflozin (SGLT2i)", finding: "First ever drug to ↓ HHF in HFpEF (26% relative risk reduction)", color: C.crimsonSoft }, { name: "SHIFT (2010)", drug: "Ivabradine", finding: "↓ HHF 26% in HFrEF with HR ≥70 in sinus rhythm on BB", color: C.grayMid }, { name: "MADIT-II / SCD-HeFT", drug: "ICD", finding: "↓ Mortality 23-31% in HFrEF (EF≤35%) with prior MI", color: C.navyMid }, ]; trials.forEach((t, i) => { const row = Math.floor(i / 2); const col = i % 2; const x = 0.2 + col * 4.9; const y = 0.9 + row * 0.87; s.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 0.8, fill: { color: C.navyMid }, line: { color: t.color, width: 1.5 } }); s.addShape(pres.ShapeType.rect, { x, y, w: 1.6, h: 0.8, fill: { color: t.color } }); s.addText(t.name, { x: x + 0.05, y, w: 1.5, h: 0.4, fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" }); s.addText(t.drug, { x: x + 0.05, y: y + 0.38, w: 1.5, h: 0.38, fontSize: 8.5, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", italic: true }); s.addText(t.finding, { x: x + 1.68, y, w: 2.88, h: 0.8, fontSize: 9.5, color: C.offWhite, valign: "middle", fontFace: "Calibri" }); }); } // ══════════════════════════════════════════════════════════════ // SLIDE 23 — EXAM HIGH-YIELD SUMMARY // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.offWhite } }); addTitle(s, "High-Yield Exam Points — Heart Failure"); const hyd = [ "1st choice in HFrEF: ACEi + BB + MRA + SGLT2i (\"Fantastic Four\") — ALL have mortality benefit", "ARNI (Sacubitril/Valsartan) SUPERIOR to ACEi — switch if tolerated; 36h washout before switching from ACEi", "Diuretics ONLY for symptoms (decongestion) — NO mortality benefit", "ICD indication: EF ≤35% after ≥3 months GDMT, NYHA II-III, life expectancy >1 yr", "CRT indication: EF ≤35% + LBBB + QRS ≥150ms + NYHA II-IV", "HFpEF: Only SGLT2i (empagliflozin) shown to reduce hospitalization (EMPEROR-Preserved)", "Cardiogenic shock: Noradrenaline → vasopressor; Dobutamine → inotrope; Emergency PCI if ACS", "Digoxin: Narrow therapeutic index; toxicity worsened by hypokalaemia; target level 0.5–0.9 ng/mL", "BB in HF: AVOID in acute decompensation; CONTINUE if already on (do not stop abruptly)", "RV infarction: Elevated JVP + clear lungs + hypotension → GIVE FLUIDS, avoid nitrates/diuretics", "PPCM: Avoid ACEi/ARB/SGLT2i/MRA in pregnancy — use Hydralazine + Nitrates + Furosemide", "Precipitants of AHF (FAILURE): Forgot meds, Arrhythmia, Ischaemia, Lifestyle excess, Uncontrolled HTN, Renal failure, Embolism/Endocarditis" ]; const half = Math.ceil(hyd.length / 2); const left = hyd.slice(0, half); const right = hyd.slice(half); s.addText(left.map((t, i) => ({ text: t, options: { bullet: { type: "number" }, breakLine: i < left.length - 1, fontSize: 10.5, color: C.darkText, fontFace: "Calibri" } })), { x: 0.2, y: 0.88, w: 4.7, h: 4.5, valign: "top" }); s.addText(right.map((t, i) => ({ text: t, options: { bullet: { type: "number" }, breakLine: i < right.length - 1, fontSize: 10.5, color: C.darkText, fontFace: "Calibri" } })), { x: 5.1, y: 0.88, w: 4.7, h: 4.5, valign: "top" }); } // ══════════════════════════════════════════════════════════════ // SLIDE 24 — THANK YOU / SUMMARY SLIDE // ══════════════════════════════════════════════════════════════ { const s = pres.addSlide(); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: "100%", fill: { color: C.navy } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: "100%", h: 0.12, fill: { color: C.crimson } }); s.addShape(pres.ShapeType.rect, { x: 0, y: 5.5, w: "100%", h: 0.12, fill: { color: C.crimson } }); s.addText("♥", { x: 4.2, y: 0.3, w: 1.6, h: 1.4, fontSize: 72, color: C.crimson, align: "center", valign: "middle" }); s.addText("SUMMARY", { x: 1, y: 1.55, w: 7.8, h: 0.65, fontSize: 32, bold: true, color: C.white, align: "center", charSpacing: 6, fontFace: "Calibri" }); s.addShape(pres.ShapeType.line, { x: 2, y: 2.25, w: 5.8, h: 0, line: { color: C.crimson, width: 2 } }); const summary = [ "GDMT is the cornerstone: ARNI/ACEi + BB + MRA + SGLT2i for HFrEF", "Diuretics relieve symptoms; devices (ICD/CRT) improve prognosis", "HFpEF: Treat comorbidities; SGLT2i now evidence-based", "Acute HF: LMNOP + identify and treat precipitants", "Special populations require individualized drug selection", "Trials: PARADIGM-HF, DAPA-HF, EMPEROR-Preserved are essential" ]; s.addText(summary.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < summary.length - 1, fontSize: 13, color: C.offWhite, fontFace: "Calibri" } })), { x: 1.5, y: 2.4, w: 7, h: 2.8, valign: "top" }); s.addText("References: ACC/AHA 2022 HF Guidelines | ESC 2021 HF Guidelines | Goodman & Gilman's Pharmacology | Braunwald's Heart Disease | Tintinalli's Emergency Medicine", { x: 0.5, y: 5.2, w: 9, h: 0.35, fontSize: 8.5, color: C.grayMid, fontFace: "Calibri", italic: true, align: "center" }); } // ══════════════════════════════════════════════════════════════ // SAVE // ══════════════════════════════════════════════════════════════ pres.writeFile({ fileName: "/home/daytona/workspace/heart-failure-pptx/Heart_Failure_Treatment_MBBS.pptx" }) .then(() => console.log("DONE: Presentation saved.")) .catch(err => { console.error("ERROR:", err); process.exit(1); });