"chest pain" evaluation guidelines

mkdir -p /home/daytona/workspace/chest-pain-ppt && ls /home/daytona/workspace/ch…

~/chest-pain-ppt/chest_pain.js

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pres.author = "Harrison's Principles of Internal Medicine 22E | Rosen's Emergency Medicine | Tintinalli's Emergency Medicine";

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// ════════════════════════════════════════════════════════════════════
//  SLIDE 1 – TITLE
// ════════════════════════════════════════════════════════════════════
titleSlide(
  "Approach to Chest Pain",
  "Harrison's Principles of Internal Medicine 22E (2025)  •  Rosen's Emergency Medicine  •  Tintinalli's EM\nLatest ACC/AHA 2021 Chest Pain Guidelines",
  C.navy
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 2 – OVERVIEW / LEARNING OBJECTIVES
// ════════════════════════════════════════════════════════════════════
contentSlide("Learning Objectives", [
  { text: "Define chest pain and recognise its broad differential diagnosis", bold: true },
  { text: "Apply a systematic history & physical examination approach" },
  { text: "Identify the 'Must-Not-Miss' life-threatening diagnoses (ACS, Aortic Dissection, PE)", red: true, bold: true },
  { text: "Select and interpret key investigations: ECG, troponins, imaging" },
  { text: "Apply validated risk stratification tools (HEART Score, TIMI, Wells)" },
  { text: "Outline evidence-based initial management for each major cause" },
  { text: "Distinguish acute vs. subacute/chronic presentations and triage appropriately" },
], { source: "Harrison's 22E, Ch. 15 | ACC/AHA 2021" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 3 – SECTION: EPIDEMIOLOGY
// ════════════════════════════════════════════════════════════════════
sectionHeader("Epidemiology & Clinical Importance", "Why chest pain matters in every clinical setting");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 4 – EPIDEMIOLOGY
// ════════════════════════════════════════════════════════════════════
contentSlide("Epidemiology of Chest Pain", [
  { text: "~7 million chest pain ED visits per year in the United States alone", bold: true },
  { text: ">50% are admitted or placed in observation units" },
  { text: "Only ~10% ultimately diagnosed with ACS", teal: true },
  { text: "~2% of AMIs are missed on first ED presentation — with double in-hospital mortality", red: true, bold: true },
  { text: "Most common final diagnoses after workup:", bold: true },
  { text: "Musculoskeletal / chest wall pain (~43%)", indent: 1 },
  { text: "Gastrointestinal (GERD, esophageal) (~14%)", indent: 1 },
  { text: "Cardiac ischemia / ACS (~12–16%)", indent: 1, red: true },
  { text: "Pulmonary (pleuritis, PE, pneumonia) (~5%)", indent: 1 },
  { text: "Psychiatric / anxiety (~5%)", indent: 1 },
  { text: "Aortic / vascular (<2%)", indent: 1, red: true },
], { source: "Harrison's 22E Fig 15-1; Tintinalli's EM" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 5 – SECTION: DIFFERENTIAL DIAGNOSIS
// ════════════════════════════════════════════════════════════════════
sectionHeader("Differential Diagnosis", "Organised from life-threatening to benign");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 6 – DIFFERENTIAL DIAGNOSIS (two columns)
// ════════════════════════════════════════════════════════════════════
twoColSlide(
  "Differential Diagnosis of Chest Pain",
  [
    { text: "LIFE-THREATENING — Must Not Miss", bold: true, red: true, bullet: false },
    { text: "Acute Coronary Syndrome (STEMI / NSTEMI / UA)", red: true },
    { text: "Acute Aortic Syndrome (dissection, IMH, aneurysm)", red: true },
    { text: "Pulmonary Embolism", red: true },
    { text: "Tension Pneumothorax", red: true },
    { text: "Pericarditis with Tamponade", red: true },
    { text: "Esophageal Rupture (Boerhaave's)", red: true },
    { text: "" },
    { text: "SERIOUS — Urgent Evaluation", bold: true, orange: true, bullet: false },
    { text: "Stable Angina / Microvascular disease", orange: true },
    { text: "Myocarditis / Acute Pericarditis", orange: true },
    { text: "Pneumonia / Pleuritis", orange: true },
    { text: "Simple Pneumothorax", orange: true },
  ],
  [
    { text: "BENIGN — Common Causes", bold: true, green: true, bullet: false },
    { text: "Musculoskeletal / Costochondritis", green: true },
    { text: "GERD / Esophageal Spasm", green: true },
    { text: "Peptic Ulcer Disease", green: true },
    { text: "Anxiety / Panic Disorder", green: true },
    { text: "Biliary Colic / Cholecystitis", green: true },
    { text: "Herpes Zoster", green: true },
    { text: "Cervical Disk Disease" },
    { text: "" },
    { text: "OTHER", bold: true, teal: true, bullet: false },
    { text: "Cardiac arrhythmia", teal: true },
    { text: "Hypertensive emergency", teal: true },
    { text: "Mediastinal mass / lymphoma", teal: true },
    { text: "Referred pain (abdominal)", teal: true },
  ],
  { leftHead: "CARDIAC / VASCULAR / PULMONARY", rightHead: "BENIGN / OTHER", leftColor: C.red, rightColor: C.teal, source: "Harrison's 22E Table 15-1 | Symptom to Diagnosis 4E" }
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 7 – SECTION: PATHOPHYSIOLOGY
// ════════════════════════════════════════════════════════════════════
sectionHeader("Pathophysiology of Chest Pain", "Somatic vs. visceral pain pathways");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 8 – PATHOPHYSIOLOGY
// ════════════════════════════════════════════════════════════════════
contentSlide("Pathophysiology", [
  { text: "Somatic pain fibers (chest wall → dermis to parietal pleura):", bold: true, teal: true },
  { text: "Enter spinal cord at specific dermatome levels", indent: 1 },
  { text: "Pain is sharp, well-localised, easily described", indent: 1 },
  { text: "Visceral pain fibers (heart, aorta, esophagus, pleura):", bold: true, teal: true },
  { text: "Map to parietal cortex at cord levels shared with somatic fibers", indent: 1 },
  { text: "Pain is vague, heavy, pressure-like — poorly localised", indent: 1 },
  { text: "Referred pain: ACS pain may radiate to neck, jaw, left arm — via shared T1–T4 pathways", indent: 1, red: true },
  { text: "Myocardial ischemia: O₂ demand > supply → anaerobic metabolism → adenosine, bradykinin release → stimulate chemosensitive afferents", bold: false },
  { text: "Factors modifying pain perception:", bold: true },
  { text: "Age, sex, DM (silent ischemia), psychiatric disease, cultural background, medications", indent: 1 },
  { text: "Women, elderly, diabetics more likely to have atypical/non-classic presentations", red: true, indent: 1, bold: true },
], { source: "Harrison's 22E; Tintinalli's EM 9E" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 9 – SECTION: CLINICAL APPROACH
// ════════════════════════════════════════════════════════════════════
sectionHeader("Clinical Approach", "History · Physical Examination · Initial Priorities");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 10 – HARRISON'S FRAMEWORK (4 QUESTIONS)
// ════════════════════════════════════════════════════════════════════
boxSlide(
  "Harrison's 22E: Structured Evaluation Framework (Table 15-2)",
  [
    { label: "Question 1", text: "Could this be an ACUTE LIFE-THREATENING condition?\nACS • Aortic Dissection • PE • Tension Pneumothorax", color: C.red },
    { label: "Question 2", text: "Could this be a CHRONIC condition risking serious complications?\nStable Angina • Aortic Stenosis • Pulmonary Hypertension", color: C.orange },
    { label: "Question 3", text: "Could this be an ACUTE condition needing specific treatment?\nPericarditis • Pneumonia/Pleuritis • Herpes Zoster", color: C.amber },
    { label: "Question 4", text: "Could this be another TREATABLE CHRONIC condition?\nGERD • Esophageal Spasm • PUD • Costochondritis • Anxiety", color: C.teal },
  ],
  { cols: 2, bh: 1.8, source: "Harrison's 22E, Table 15-2 (Thomas H. Lee framework)", footer: "These four questions structure every chest pain evaluation — acute setting or outpatient" }
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 11 – HISTORY: INITIAL ASSESSMENT
// ════════════════════════════════════════════════════════════════════
contentSlide("Initial Assessment: Immediate Priorities", [
  { text: "Triage immediately if ANY of the following:", bold: true, red: true },
  { text: "Abnormal vital signs (hypotension, tachycardia, hypoxia)", red: true, indent: 1 },
  { text: "ECG findings of ischemia or injury (ST elevation/depression, LBBB)", red: true, indent: 1 },
  { text: "Prior CAD history or multiple cardiovascular risk factors", red: true, indent: 1 },
  { text: "Abrupt, new, or severe chest pain with diaphoresis / syncope", red: true, indent: 1 },
  { text: "Immediate actions:", bold: true, teal: true },
  { text: "Airway · Breathing · Circulation assessment", teal: true, indent: 1 },
  { text: "Cardiac monitoring + IV access", teal: true, indent: 1 },
  { text: "12-lead ECG within 10 minutes of arrival", teal: true, bold: true, indent: 1 },
  { text: "Supplemental O₂ if SpO₂ <94%", teal: true, indent: 1 },
  { text: "Serial vital signs at regular intervals", indent: 1 },
  { text: "Chest radiograph to exclude immediate life-threatening processes", indent: 1 },
], { source: "Tintinalli's EM 9E; Harrison's 22E; ACC/AHA 2021" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 12 – HISTORY: PAIN CHARACTERISTICS (OPQRST)
// ════════════════════════════════════════════════════════════════════
contentSlide("History: Pain Characteristics (OPQRST)", [
  { text: "Onset: Sudden (dissection, PE, pneumothorax) vs. gradual (musculoskeletal, GERD)", bold: true },
  { text: "Provocation/Palliation:", bold: true },
  { text: "Exertional — angina (2–10 min rest relief), PE", indent: 1 },
  { text: "Positional — worse supine → pericarditis; worse lying → GERD", indent: 1 },
  { text: "Pleuritic (sharp, worse with breathing) — PE, pneumonia, pericarditis, pneumothorax", indent: 1 },
  { text: "Palpation-reproducible — musculoskeletal (but 15% of ACS also have this)", indent: 1, orange: true },
  { text: "Quality:", bold: true },
  { text: "Crushing / pressure / tightness → ACS ('classic' angina)", red: true, indent: 1 },
  { text: "Tearing / ripping → Aortic Dissection", red: true, indent: 1 },
  { text: "Sharp / stabbing → pleuritic causes, musculoskeletal", indent: 1 },
  { text: "Radiation: Left arm / jaw / neck → ACS  |  Inter-scapular → Aortic Dissection  |  Shoulder tip → phrenic irritation", bold: true },
  { text: "Severity & Time: ACS pain >20 min; STEMI >30 min; unstable angina new/at-rest/crescendo", bold: true },
], { source: "Harrison's 22E; Tintinalli's EM 9E" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 13 – HISTORY: ATYPICAL PRESENTATIONS
// ════════════════════════════════════════════════════════════════════
contentSlide("Atypical Presentations — High-Risk Groups", [
  { text: "Non-classic ACS presentations are common — do NOT rule out ACS based on atypical symptoms alone", red: true, bold: true },
  { text: "22% of AMI patients describe pain as 'sharp or stabbing' (Multicenter Chest Pain Study)", red: true },
  { text: "High-risk groups for atypical ACS presentations:", bold: true },
  { text: "Women — pain unrelated to exertion, jaw/neck/back pain, fatigue, palpitations", indent: 1, orange: true },
  { text: "Elderly — dyspnea, syncope, altered mental status, generalized weakness", indent: 1, orange: true },
  { text: "Diabetics — silent ischemia, autonomic neuropathy blunts pain", indent: 1, orange: true },
  { text: "Racial minorities — more atypical, subject to diagnostic delays", indent: 1, orange: true },
  { text: "Anginal equivalents (no chest pain at all):", bold: true, red: true },
  { text: "Dyspnea at rest / exertion, nausea, diaphoresis, lightheadedness, jaw/arm/shoulder discomfort", indent: 1, red: true },
  { text: "47% of 721 consecutive MI patients presented WITHOUT chest pain (large urban hospital study)", red: true, bold: true },
], { source: "Tintinalli's EM 9E; Harrison's 22E" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 14 – PHYSICAL EXAM
// ════════════════════════════════════════════════════════════════════
twoColSlide(
  "Physical Examination in Chest Pain",
  [
    { text: "Vital Signs (critical first step)", bold: true, teal: true, bullet: false },
    { text: "BP both arms (>20 mmHg difference → dissection)", red: true },
    { text: "HR, RR, SpO₂ — oxygen if <94%" },
    { text: "Temperature (fever → infection, pericarditis)" },
    { text: "General Inspection", bold: true, teal: true, bullet: false },
    { text: "Diaphoresis, pallor, cyanosis, distress level" },
    { text: "Thorax: symmetry, deformity, surgical scars" },
    { text: "Cardiovascular", bold: true, teal: true, bullet: false },
    { text: "Murmurs → AS, MR (ischemic), AR (dissection)" },
    { text: "S3 gallop, JVD, pericardial friction rub" },
    { text: "Distant heart sounds → tamponade" },
    { text: "Pulsus paradoxus →tamponade" },
  ],
  [
    { text: "Pulmonary", bold: true, orange: true, bullet: false },
    { text: "Absent breath sounds + tracheal shift → pneumothorax" },
    { text: "Unilateral dullness → pleural effusion, hemothorax" },
    { text: "Crepitations → pulmonary edema" },
    { text: "Abdomen", bold: true, orange: true, bullet: false },
    { text: "Epigastric tenderness → PUD, pancreatitis" },
    { text: "Chest Wall Palpation", bold: true, orange: true, bullet: false },
    { text: "Point tenderness → costochondritis, Tietze's syndrome" },
    { text: "Note: Reproducible tenderness does NOT rule out ACS", orange: true },
    { text: "Skin / Neurological", bold: true, orange: true, bullet: false },
    { text: "Vesicular rash in dermatomal pattern → Herpes Zoster" },
    { text: "Peripheral pulses — asymmetry → dissection" },
    { text: "Leg swelling / tenderness → DVT + PE", red: true },
  ],
  { leftHead: "CARDIOVASCULAR EXAMINATION", rightHead: "PULMONARY / OTHER SYSTEMS", source: "Harrison's 22E; Rosen's 10E" }
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 15 – SECTION: INVESTIGATIONS
// ════════════════════════════════════════════════════════════════════
sectionHeader("Investigations", "ECG · Biomarkers · Imaging · Laboratory");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 16 – 12-LEAD ECG
// ════════════════════════════════════════════════════════════════════
contentSlide("12-Lead ECG — The Most Urgent Test", [
  { text: "Perform within 10 minutes of ED arrival — ECG is diagnostic in STEMI", red: true, bold: true },
  { text: "STEMI criteria (4th Universal Definition of MI):", bold: true },
  { text: "ST elevation >1 mm in ≥2 contiguous leads (except V₂–V₃)", indent: 1 },
  { text: "V₂–V₃: ≥1.5 mm women; ≥2.5 mm men <40 yr; ≥2 mm men ≥40 yr", indent: 1, red: true },
  { text: "New LBBB with ACS symptoms — treat as STEMI equivalent", red: true, indent: 1 },
  { text: "NSTEMI / UA: ST depression, T-wave inversions, dynamic changes", bold: true },
  { text: "High-risk ECG features:", bold: true, orange: true },
  { text: "Wellens' patterns (T-wave inversions V₁–V₄) → LAD stenosis", orange: true, indent: 1 },
  { text: "DeWinter T waves → anterior STEMI equivalent", orange: true, indent: 1 },
  { text: "Posterior STEMI (STD in V₁–V₃ + dominant R) — check posterior leads V₇–V₉", orange: true, indent: 1 },
  { text: "Other diagnoses suggested by ECG:", bold: true },
  { text: "S1Q3T3 → PE  |  Diffuse saddle-shaped ST elevation → Pericarditis  |  Sinus tachycardia → PE/anxiety/sepsis", indent: 1 },
  { text: "A normal ECG does NOT rule out ACS — negative predictive value not 100% even at 12 hours", red: true, bold: true },
], { source: "Harrison's 22E; Rosen's EM 10E; 4th Universal Definition of MI (ESC 2018)" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 17 – CARDIAC BIOMARKERS
// ════════════════════════════════════════════════════════════════════
contentSlide("Cardiac Biomarkers", [
  { text: "High-Sensitivity Troponin (hs-cTn) — PREFERRED biomarker for MI diagnosis", bold: true, red: true },
  { text: "Measure at presentation (0h) and repeat at 1–2h (hs-cTn) or 3–6h (conventional)", indent: 1 },
  { text: "Patients >2–3h after onset: very low hs-cTn at presentation → NPV >99% for MI", green: true, indent: 1 },
  { text: "Rising/falling pattern + at least one value >99th percentile = required for MI diagnosis", indent: 1, bold: true },
  { text: "Troponin elevations in non-ACS conditions:", bold: true, orange: true },
  { text: "Myocarditis, PE, heart failure, sepsis, renal failure, Takotsubo — clinical context is critical", orange: true, indent: 1 },
  { text: "Type 1 MI: coronary atherothrombosis  |  Type 2 MI: supply-demand mismatch (anemia, tachycardia, sepsis)", indent: 1 },
  { text: "Other key biomarkers:", bold: true },
  { text: "D-dimer — rule-out PE (Wells score <2 + neg D-dimer → PE excluded)", teal: true, indent: 1 },
  { text: "BNP/NT-proBNP — heart failure evaluation", teal: true, indent: 1 },
  { text: "CRP, ESR — pericarditis, myocarditis", teal: true, indent: 1 },
  { text: "CBC, metabolic panel, ABG — secondary causes of ischemia (anemia, hypoxia)", teal: true, indent: 1 },
], { source: "Harrison's 22E; ESC 2020 NSTE-ACS Guidelines; ACC/AHA 2021" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 18 – IMAGING
// ════════════════════════════════════════════════════════════════════
contentSlide("Imaging in Chest Pain", [
  { text: "Chest X-Ray (CXR) — routine for all acute chest pain presentations", bold: true, teal: true },
  { text: "Mediastinal widening → aortic dissection", indent: 1, red: true },
  { text: "Hampton's hump / Westermark's sign → pulmonary embolism", indent: 1 },
  { text: "Absent lung markings → pneumothorax", indent: 1 },
  { text: "Pulmonary edema → ACS with LV failure, myocarditis", indent: 1 },
  { text: "CT Pulmonary Angiography (CTPA) — gold standard for PE", bold: true, teal: true },
  { text: "CT Aortography — gold standard for aortic dissection", bold: true, red: true },
  { text: "Echocardiography — LV function, wall motion abnormalities, effusion, tamponade, valvular disease", bold: true, teal: true },
  { text: "Coronary CT Angiography (CCTA) — for stable/intermediate-risk chest pain, outpatient", teal: true },
  { text: "Stress Testing (ETT / Stress Echo / Nuclear / Stress CMR):", bold: true },
  { text: "For stable, low-to-intermediate-risk patients after ACS excluded", indent: 1 },
  { text: "Invasive Coronary Angiography — high-risk NSTE-ACS, ongoing ischemia, STEMI", red: true, bold: true, indent: 1 },
], { source: "Harrison's 22E; ACC/AHA 2021 Chest Pain Guidelines; ESCR 2024" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 19 – SECTION: RISK STRATIFICATION
// ════════════════════════════════════════════════════════════════════
sectionHeader("Risk Stratification", "HEART Score · TIMI · Wells · ESC 0/1h · 0/2h Protocols");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 20 – HEART SCORE
// ════════════════════════════════════════════════════════════════════
boxSlide(
  "HEART Score — Risk Stratification for ACS in ED",
  [
    { label: "H – History", text: "0: Slightly suspicious\n1: Moderately suspicious\n2: Highly suspicious", color: C.blue },
    { label: "E – ECG", text: "0: Normal\n1: Non-specific repolarisation disturbance\n2: Significant ST deviation", color: C.blue },
    { label: "A – Age", text: "0: <45 yr\n1: 45–64 yr\n2: ≥65 yr", color: C.blue },
    { label: "R – Risk Factors", text: "0: No known risk factors\n1: 1–2 risk factors / obesity / active smoker\n2: Known atherosclerotic disease or ≥3 risk factors", color: C.blue },
    { label: "T – Troponin", text: "0: ≤Normal limit\n1: 1–3× normal limit\n2: >3× normal limit", color: C.blue },
    { label: "Score Interpretation", text: "0–3 (LOW): 1.7% MACE — consider early discharge + outpatient follow-up\n4–6 (MODERATE): 12–16.6% MACE — observation + serial troponins\n7–10 (HIGH): 50–65% MACE — early invasive strategy", color: C.red },
  ],
  { cols: 3, bh: 1.55, source: "Rosen's EM 10E; HEART Pathway (Six et al.)", footer: "HEART Pathway (HEART Score 0–3 + serial troponin negative) = safe for early discharge" }
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 21 – ESC 0/1h PROTOCOL
// ════════════════════════════════════════════════════════════════════
contentSlide("ESC Rapid Rule-Out Protocols (2020 NSTE-ACS Guidelines)", [
  { text: "ESC 0h/1h Algorithm (Preferred — uses hs-cTn):", bold: true, teal: true },
  { text: "RULE OUT (0h/1h): Very low hs-cTnI (<5 ng/L) at 0h + change <6 ng/L at 1h → discharge (NPV >99%)", green: true, bold: true, indent: 1 },
  { text: "RULE IN (0h/1h): hs-cTnI >52 ng/L at 0h OR change >6 ng/L at 1h → diagnose NSTEMI", red: true, bold: true, indent: 1 },
  { text: "OBSERVE zone: Does not meet rule-in or rule-out → serial testing to 3h", orange: true, indent: 1 },
  { text: "ESC 0h/2h Algorithm (Alternative):", bold: true, teal: true },
  { text: "Low hs-cTnI (<12 ng/L) at 0h + change <4 ng/L at 2h → rule out", green: true, indent: 1 },
  { text: "TIMI Risk Score (0–7 points) — for NSTE-ACS:", bold: true },
  { text: "Age ≥65, ≥3 CAD risk factors, prior coronary stenosis ≥50%, ST deviation, ≥2 anginal events in 24h, prior aspirin use, elevated cardiac markers", indent: 1 },
  { text: "Score ≥3 → high risk → early invasive strategy", red: true, bold: true, indent: 1 },
  { text: "GRACE Score — validated risk model for NSTE-ACS in-hospital and 6-month mortality", bold: true },
  { text: "High GRACE → early invasive strategy within 24h; very-high GRACE → immediate (<2h) angiography", red: true, indent: 1 },
], { source: "ESC 2020 NSTE-ACS Guidelines; Collet et al. Eur Heart J 2021" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 22 – SECTION: KEY DIAGNOSES IN DETAIL
// ════════════════════════════════════════════════════════════════════
sectionHeader("Key Diagnoses — Detailed Overview", "ACS · Aortic Dissection · PE · Pneumothorax · Pericarditis");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 23 – ACS
// ════════════════════════════════════════════════════════════════════
contentSlide("Acute Coronary Syndrome (ACS)", [
  { text: "Definition: Spectrum of unstable ischemic heart disease — unstable angina, NSTEMI, STEMI", bold: true, red: true },
  { text: "Pathophysiology: Atherosclerotic plaque rupture → thrombus → coronary occlusion", indent: 1 },
  { text: "Classic presentation:", bold: true },
  { text: "Retrosternal crushing / pressure radiating to left arm, jaw, or neck", indent: 1 },
  { text: "Diaphoresis, dyspnea, nausea/vomiting", indent: 1 },
  { text: "ECG: STEMI criteria or dynamic ST/T changes; Biomarker: Rising hs-cTn", indent: 1 },
  { text: "Management:", bold: true, teal: true },
  { text: "STEMI: Primary PCI within 90 min (door-to-balloon time) — first-line revascularisation", red: true, indent: 1, bold: true },
  { text: "Antiplatelet: Aspirin 325 mg + P2Y12 inhibitor (ticagrelor / prasugrel / clopidogrel)", teal: true, indent: 1 },
  { text: "Anticoagulation: UFH, LMWH, bivalirudin, or fondaparinux", teal: true, indent: 1 },
  { text: "NSTEMI/UA: Risk-stratify with HEART / GRACE / TIMI → early invasive vs. conservative", teal: true, indent: 1 },
  { text: "Beta-blockers, statins, ACE inhibitors — initiated for MI management", teal: true, indent: 1 },
], { source: "Harrison's 22E; ACC/AHA 2021 Chest Pain Guidelines; ESC 2020" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 24 – AORTIC DISSECTION
// ════════════════════════════════════════════════════════════════════
contentSlide("Acute Aortic Syndrome — Aortic Dissection", [
  { text: "Presentation: ABRUPT maximal-intensity tearing / ripping pain — chest + back / inter-scapular", bold: true, red: true },
  { text: "BP difference >20 mmHg between arms, pulse deficits, aortic regurgitation murmur, neurological deficits", red: true },
  { text: "Risk factors: Hypertension (most common), Marfan syndrome, bicuspid aortic valve, connective tissue disorders, cocaine", indent: 1 },
  { text: "Stanford Classification:", bold: true, teal: true },
  { text: "Type A (ascending aorta involved) — SURGICAL EMERGENCY", red: true, bold: true, indent: 1 },
  { text: "Type B (descending aorta only) — Medical management (BP control) unless complicated", teal: true, indent: 1 },
  { text: "Investigations:", bold: true },
  { text: "CXR: widened mediastinum (>8 cm), loss of aortic knuckle", indent: 1 },
  { text: "CT Aortography: gold standard — entire aorta", indent: 1, bold: true },
  { text: "TEE — if CT unavailable or hemodynamically unstable", indent: 1 },
  { text: "Management:", bold: true, teal: true },
  { text: "HR <60 bpm and SBP 100–120 mmHg → IV beta-blockers (labetalol/esmolol) + vasodilators", teal: true, indent: 1 },
  { text: "Do NOT give fibrinolytics — catastrophic haemorrhage risk", red: true, bold: true, indent: 1 },
], { source: "Harrison's 22E; Fuster & Hurst's The Heart 15E; Rosen's EM" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 25 – PULMONARY EMBOLISM
// ════════════════════════════════════════════════════════════════════
contentSlide("Pulmonary Embolism (PE)", [
  { text: "Presentation: Pleuritic chest pain, dyspnea (most common), tachycardia, hypoxia, haemoptysis", bold: true },
  { text: "Massive PE: Haemodynamic instability, right heart strain, syncope — HIGH MORTALITY", red: true, bold: true },
  { text: "Risk factors: DVT, malignancy, immobilisation, surgery, OCP, thrombophilia, long-haul travel" },
  { text: "Wells Score for PE:", bold: true, teal: true },
  { text: "≤4 (low probability): D-dimer → if negative, PE excluded", green: true, indent: 1 },
  { text: ">4 (high probability): Proceed directly to CTPA", red: true, indent: 1 },
  { text: "Investigations:", bold: true },
  { text: "ECG: Sinus tachycardia, S1Q3T3, new RBBB, AF — none pathognomonic", indent: 1 },
  { text: "CTPA — gold standard  |  V/Q scan — alternative (renal impairment, contrast allergy)", indent: 1 },
  { text: "Echo: RV dilation / strain, McConnell's sign — useful in massive PE", indent: 1 },
  { text: "Management:", bold: true, teal: true },
  { text: "Anticoagulation — LMWH/UFH bridge to DOAC/warfarin (DOACs preferred per ESC 2019)", teal: true, indent: 1 },
  { text: "Massive PE: Thrombolysis (alteplase) or surgical/catheter-directed embolectomy", red: true, bold: true, indent: 1 },
], { source: "Harrison's 22E; ESC 2019 PE Guidelines; Fuster & Hurst's 15E" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 26 – PNEUMOTHORAX + PERICARDITIS
// ════════════════════════════════════════════════════════════════════
twoColSlide(
  "Pneumothorax & Pericarditis",
  [
    { text: "Pneumothorax", bold: true, red: true, bullet: false },
    { text: "Sudden sharp pleuritic pain + dyspnea" },
    { text: "Tension PTX: Tracheal deviation AWAY, absent sounds, haemodynamic collapse — EMERGENCY", red: true, bold: true },
    { text: "Causes: Spontaneous (young tall male), trauma, iatrogenic, COPD, Marfan's" },
    { text: "Dx: CXR (absent lung markings, pleural line), POCUS (absent lung sliding)", teal: true },
    { text: "Rx:", bold: true },
    { text: "Tension: Immediate needle decompression (2nd ICS MCL) + chest drain", red: true, indent: 1 },
    { text: "Simple large: Chest drain", teal: true, indent: 1 },
    { text: "Small/primary: Aspiration or observation", green: true, indent: 1 },
  ],
  [
    { text: "Pericarditis", bold: true, orange: true, bullet: false },
    { text: "Sharp pleuritic chest pain — worse supine, relieved leaning forward" },
    { text: "Pericardial friction rub (pathognomonic but transient)" },
    { text: "ECG: Diffuse saddle-shaped ST elevation, PR depression (except aVR)" },
    { text: "Causes: Viral (most common), autoimmune, post-MI (Dressler), malignancy, uremia" },
    { text: "Echo: Pericardial effusion — assess for tamponade" },
    { text: "Tamponade: Beck's triad (JVD + hypotension + muffled sounds) + pulsus paradoxus", red: true, bold: true },
    { text: "Rx:", bold: true },
    { text: "NSAIDs + Colchicine — first-line (reduces recurrence)", teal: true, indent: 1 },
    { text: "Avoid NSAIDs in early MI (STEMI-related pericarditis)", orange: true, indent: 1 },
    { text: "Pericardiocentesis if tamponade", red: true, indent: 1 },
  ],
  { leftHead: "PNEUMOTHORAX", rightHead: "PERICARDITIS / TAMPONADE", source: "Harrison's 22E; ESC 2015 Pericardial Diseases" }
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 27 – BENIGN CAUSES
// ════════════════════════════════════════════════════════════════════
twoColSlide(
  "Common Benign Causes of Chest Pain",
  [
    { text: "Musculoskeletal / Costochondritis", bold: true, green: true, bullet: false },
    { text: "Most common cause (~43% of chest pain)" },
    { text: "Reproducible with palpation, localised tenderness" },
    { text: "Tietze's syndrome: tender swelling at costochondral junction" },
    { text: "Rx: NSAIDs, rest, physio" },
    { text: "" },
    { text: "GERD / Esophageal Spasm", bold: true, green: true, bullet: false },
    { text: "Burning retrosternal pain, worse lying, relieved by antacids" },
    { text: "Esophageal spasm: Severe, cramping, mimics ACS — may respond to nitrates" },
    { text: "Dx: PPI trial (GERD); manometry, barium swallow (spasm)" },
    { text: "Note: Exclude cardiac cause BEFORE attributing to GI/esophageal etiology", orange: true, bold: true },
  ],
  [
    { text: "Anxiety / Panic Disorder", bold: true, green: true, bullet: false },
    { text: "Atypical pains, often pleuritic or diffuse" },
    { text: "Associated with hyperventilation, palpitations, tremor" },
    { text: "Diagnosis of exclusion — rule out cardiac cause first", orange: true, bold: true },
    { text: "" },
    { text: "Herpes Zoster", bold: true, green: true, bullet: false },
    { text: "Dermatomal pain precedes vesicular rash by 2–3 days" },
    { text: "May mimic ACS or pleurisy — look for rash" },
    { text: "Rx: Antivirals (acyclovir/valacyclovir) within 72h" },
    { text: "" },
    { text: "Biliary / GI Causes", bold: true, green: true, bullet: false },
    { text: "Right upper quadrant / epigastric pain radiating to right scapula" },
    { text: "Post-prandial, N/V — cholecystitis, biliary colic, pancreatitis" },
  ],
  { leftHead: "MUSCULOSKELETAL / GI", rightHead: "PSYCHIATRIC / INFECTIOUS / BILIARY", source: "Harrison's 22E; Symptom to Diagnosis 4E" }
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 28 – SECTION: MANAGEMENT OVERVIEW
// ════════════════════════════════════════════════════════════════════
sectionHeader("Management Algorithm", "Acute Chest Pain — Decision Framework");

// ════════════════════════════════════════════════════════════════════
//  SLIDE 29 – MANAGEMENT FLOW
// ════════════════════════════════════════════════════════════════════
contentSlide("Acute Chest Pain Management Algorithm", [
  { text: "STEP 1 — Immediate Stabilisation (ALL patients)", bold: true, teal: true, bullet: false },
  { text: "ABC + IV access + cardiac monitoring + O₂ if SpO₂ <94% + 12-lead ECG within 10 min", teal: true, indent: 1 },
  { text: "STEP 2 — STEMI? Immediate Reperfusion", bold: true, red: true, bullet: false },
  { text: "Primary PCI (door-to-balloon ≤90 min) — OR fibrinolysis if PCI unavailable within 120 min", red: true, bold: true, indent: 1 },
  { text: "STEP 3 — Aortic Dissection / PE / Tension PTX?", bold: true, red: true, bullet: false },
  { text: "Dissection: IV beta-blockers, urgent CT aorta, surgical consult (Type A)", red: true, indent: 1 },
  { text: "PE: Anticoagulation; thrombolysis if massive PE + haemodynamic instability", red: true, indent: 1 },
  { text: "Tension PTX: Immediate needle decompression + chest drain", red: true, indent: 1 },
  { text: "STEP 4 — NSTE-ACS? Risk Stratify", bold: true, orange: true, bullet: false },
  { text: "HEART Score / GRACE + serial hs-cTn at 0h/1h (ESC) or 0h/3h (HEART Pathway)", orange: true, indent: 1 },
  { text: "High risk → early invasive angiography (<24h)  |  Low risk → discharge + outpatient follow-up", indent: 1 },
  { text: "STEP 5 — Non-cardiac cause? Targeted therapy", bold: true, green: true, bullet: false },
  { text: "GI / musculoskeletal / psychiatric / infectious — treat underlying condition", green: true, indent: 1 },
], { source: "ACC/AHA 2021 Chest Pain Guidelines; ESC 2020; Harrison's 22E" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 30 – OUTPATIENT EVALUATION
// ════════════════════════════════════════════════════════════════════
contentSlide("Outpatient Evaluation of Chest Discomfort", [
  { text: "Patients presenting with chronic or subacute (resolved) chest pain to primary care / outpatient setting:", bold: true },
  { text: "General diagnostic assessment is appropriate — no need for immediate invasive workup", teal: true },
  { text: "Priority remains: identify those with underlying coronary artery disease or structural heart disease", bold: true },
  { text: "Assess pre-test probability using clinical history + risk factors (age, sex, DM, HTN, smoking, dyslipidaemia)" },
  { text: "Diagnostic tools for stable chest pain:", bold: true, teal: true },
  { text: "Resting ECG → baseline", teal: true, indent: 1 },
  { text: "Exercise stress test (ETT) — first-line for intermediate-risk patients (normal baseline ECG)", teal: true, indent: 1 },
  { text: "CT Coronary Angiography (CCTA) — recommended by ACC/AHA 2021 for stable chest pain (intermediate pre-test probability)", teal: true, bold: true, indent: 1 },
  { text: "Stress echocardiography / nuclear imaging — if ECG uninterpretable or prior revascularisation", teal: true, indent: 1 },
  { text: "Cardiac MRI — for suspected myocarditis, cardiomyopathy", teal: true, indent: 1 },
  { text: "Echocardiogram — if structural heart disease or reduced EF suspected", indent: 1 },
], { source: "ACC/AHA 2021 Chest Pain Guidelines; Harrison's 22E" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 31 – SPECIAL POPULATIONS
// ════════════════════════════════════════════════════════════════════
contentSlide("Special Populations", [
  { text: "Women:", bold: true, teal: true },
  { text: "Higher rates of MINOCA (MI with non-obstructive coronary arteries), Takotsubo, microvascular disease", indent: 1 },
  { text: "More atypical symptoms — jaw/neck/back pain, fatigue, nausea; less diaphoresis", indent: 1 },
  { text: "Pre/early menopausal: pain not related to exertion, not relieved by rest or nitrates", indent: 1, orange: true },
  { text: "Elderly:", bold: true, teal: true },
  { text: "Silent MI, atypical presentations, multiple comorbidities, altered pain perception", indent: 1 },
  { text: "Higher risk: baseline ECG changes, renal impairment affecting troponin interpretation", indent: 1 },
  { text: "Diabetics:", bold: true, teal: true },
  { text: "Autonomic neuropathy → silent ischemia — dyspnea may be the only symptom", indent: 1 },
  { text: "Cocaine users:", bold: true, orange: true },
  { text: "Chest pain characteristics identical to atherosclerotic ACS", indent: 1 },
  { text: "Cocaine-induced coronary vasospasm + tachycardia + thrombosis", indent: 1 },
  { text: "Beta-blockers CONTRAINDICATED (unopposed alpha stimulation) — use labetalol if rate control needed", red: true, bold: true, indent: 1 },
  { text: "Pregnancy:", bold: true, teal: true },
  { text: "Aortic dissection risk ↑ (type B > A); PE risk ↑ 4-fold; peripartum cardiomyopathy; SCAD", indent: 1 },
], { source: "Harrison's 22E; Tintinalli's EM 9E; ACC/AHA 2021" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 32 – KEY SUMMARY TABLE
// ════════════════════════════════════════════════════════════════════
contentSlide("Summary: Differentiating Life-Threatening Causes", [
  { text: "ACS: Retrosternal pressure/crushing, radiation to arm/jaw, diaphoresis, exertional, relieved by nitrates", bold: false },
  { text: "   ECG: ST elevation/depression | Biomarker: Raised hs-cTn", bold: true, teal: true, bullet: false },
  { text: "Aortic Dissection: Abrupt maximal tearing/ripping pain, interscapular, BP asymmetry, pulse deficit", bold: false },
  { text: "   ECG: Normal or non-specific | CT Aorta: Diagnostic", bold: true, red: true, bullet: false },
  { text: "PE: Pleuritic pain + dyspnea + tachycardia + hypoxia; Risk factors: DVT, malignancy", bold: false },
  { text: "   ECG: Sinus tachycardia, S1Q3T3 | CTPA: Diagnostic | D-dimer if low probability", bold: true, orange: true, bullet: false },
  { text: "Tension PTX: Sudden, pleuritic, tracheal deviation, absent breath sounds, haemodynamic collapse", bold: false },
  { text: "   Dx: Clinical | Rx: Needle decompression IMMEDIATELY", bold: true, red: true, bullet: false },
  { text: "Pericarditis: Sharp pleuritic, worse supine, friction rub, saddle-shaped ST elevation, PR depression", bold: false },
  { text: "   Rx: NSAIDs + Colchicine | Echocardiogram for effusion", bold: true, teal: true, bullet: false },
  { text: "Esophageal Rupture: History of vomiting + severe chest pain; subcutaneous emphysema", bold: false, red: true },
  { text: "   Dx: CXR/CT (pneumomediastinum) | Surgical emergency", bold: true, red: true, bullet: false },
], { source: "Harrison's 22E Table 15-1; Symptom to Diagnosis 4E" });

// ════════════════════════════════════════════════════════════════════
//  SLIDE 33 – CONCLUSION
// ════════════════════════════════════════════════════════════════════
titleSlide(
  "Key Takeaways",
  "• Always rule out life-threatening causes first (ACS, Dissection, PE, Tension PTX)\n• ECG within 10 minutes — a normal ECG does NOT rule out ACS\n• High-sensitivity troponin with serial testing is the cornerstone biomarker\n• Use validated tools: HEART Score, ESC 0h/1h, GRACE, Wells\n• Recognise atypical presentations — women, elderly, diabetics\n• ACC/AHA 2021: CCTA is first-line imaging for stable intermediate-risk chest pain",
  C.navy
);

// ════════════════════════════════════════════════════════════════════
//  SLIDE 34 – REFERENCES
// ════════════════════════════════════════════════════════════════════
contentSlide("References", [
  { text: "Harrison's Principles of Internal Medicine, 22nd Edition (2025). McGraw Hill Medical. Chapter 15 (Chest Discomfort)", bold: true, teal: true },
  { text: "Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th Ed. Chapter 48 (Chest Pain)", bold: false },
  { text: "Rosen's Emergency Medicine: Concepts and Clinical Practice, 10th Ed. Chapter 64 (Chest Pain, Acute Coronary Syndromes)", bold: false },
  { text: "Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed. Chapter 9", bold: false },
  { text: "Fuster & Hurst's The Heart, 15th Ed.", bold: false },
  { text: "ACC/AHA 2021 Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation 2021", bold: true, teal: true },
  { text: "ESC 2020 Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation", bold: false },
  { text: "ESC 2019 Guidelines on acute pulmonary embolism. Eur Heart J 2020", bold: false },
  { text: "ESC 2015 Guidelines on the diagnosis and management of pericardial diseases", bold: false },
  { text: "4th Universal Definition of Myocardial Infarction. Eur Heart J 2019", bold: false },
  { text: "Six AJ, et al. HEART score: A validated risk stratification tool. Neth Heart J 2010", bold: false },
], { source: "Current as of July 2026", bg: C.offwhite });

// ════════════════════════════════════════════════════════════════════
//  WRITE FILE
// ════════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/chest-pain-ppt/Chest_Pain_Approach.pptx" })
  .then(() => console.log("PPTX created successfully"))
  .catch(e => { console.error("Error:", e); process.exit(1); });

cd /home/daytona/workspace/chest-pain-ppt && node chest_pain.js 2>&1

cd /home/daytona/workspace/chest-pain-ppt && libreoffice --headless --convert-to…

ls -la /home/daytona/workspace/chest-pain-ppt/ && mkdir -p /home/daytona/workspa…

chmod 777 /home/daytona/workspace/chest-pain-ppt/output 2>&1; libreoffice --head…

ls -la /tmp/Chest_Pain_Approach.pdf && ls -la /home/daytona/workspace/chest-pain…