Orris

I am a new Apn on the Advanced heart failure, and Transplant team. Can you please create a study guide to help me with EKGs and anti-rejection test and treatments as as well as as GDMT for heart failure, patients, etc. please make this easy to understand and comprehend, as I am just starting out in my career

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"heart failure" AND "guideline directed medical therapy"

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Welcome to the team! Here's your complete study guide — built directly from Braunwald's Heart Disease, Goldman-Cecil Medicine, Katzung's Pharmacology, and Rosen's Emergency Medicine, plus the latest 2024 ISHLT transplant guidelines.
Here's a quick map of what's covered:

What's in Your Study Guide

Part 1 — EKGs
  • The 5-step systematic approach (use it every single time)
  • Normal intervals and what abnormalities mean in HF
  • Key patterns: LBBB, RBBB, VT, A-fib, heart block
  • Special transplant EKG rules — the denervated heart is completely different (atropine is useless, half-dose adenosine, silent MIs)
Part 2 — GDMT (The "BANS" Four Pillars)
  • Beta-blocker → ARNI → New MRA → SGLT2 inhibitor
  • Mechanisms, examples, titration tips, side effects, and monitoring for each
  • Diuretics, hydralazine/nitrate, ivabradine, digoxin as add-on therapies
  • HF staging (A/B/C/D) at a glance
Part 3 — Transplant
  • The three types of rejection (hyperacute, acute cellular, antibody-mediated) and CAV
  • ISHLT biopsy grading (0R–3R) and what to do at each grade
  • Triple-drug immunosuppression: tacrolimus + mycophenolate + prednisone
  • Critical drug-drug interactions (azoles + tacrolimus, CCBs + CNIs, cyclosporine + statins)
  • Routine monitoring labs and what each one is checking for
  • Infection timeline and standard prophylaxis
Part 4 — Quick-Reference Cheat Sheets for fast bedside review
A few tips as you start out:
  1. Always check tacrolimus troughs BEFORE the morning dose — timing matters more than people realize
  2. GDMT is only started/uptitrated in the euvolemic (dry) patient — never start a beta-blocker in an acute decompensation
  3. Never use atropine on a transplant patient — it won't work and wastes precious time

Create a quick reference PDF card (front/back) with EKG findings

Reading File
Running Command

ls -la /home/daytona/workspace/ 2>/dev/null || mkdir -p /home/daytona/workspace

Running Command

mkdir -p /home/daytona/workspace/ekgcard && python3 -c "from reportlab.pdfgen im…

Writing File

~/ekgcard/build_ekg_card.py

from reportlab.pdfgen import canvas
from reportlab.lib.pagesizes import letter
from reportlab.lib import colors
from reportlab.lib.units import inch
from reportlab.platypus import Table, TableStyle
from reportlab.lib.styles import getSampleStyleSheet
from reportlab.platypus import Paragraph

# ── Palette ──────────────────────────────────────────────────────────────────
NAVY        = colors.HexColor("#0A2342")
TEAL        = colors.HexColor("#1A6B72")
LIGHT_TEAL  = colors.HexColor("#D6F0F2")
RED_ACCENT  = colors.HexColor("#C0392B")
AMBER       = colors.HexColor("#E67E22")
GREEN       = colors.HexColor("#1E8449")
WHITE       = colors.white
LIGHT_GRAY  = colors.HexColor("#F4F6F8")
MID_GRAY    = colors.HexColor("#BDC3C7")
DARK_GRAY   = colors.HexColor("#2C3E50")
YELLOW_HI   = colors.HexColor("#FDEBD0")

W, H = letter   # 8.5 × 11 inches

def header_bar(c, y, text, bg=NAVY, fg=WHITE, fontsize=11):
    c.setFillColor(bg)
    c.rect(0.35*inch, y, W - 0.7*inch, 0.28*inch, fill=1, stroke=0)
    c.setFillColor(fg)
    c.setFont("Helvetica-Bold", fontsize)
    c.drawCentredString(W/2, y + 0.06*inch, text)

def section_header(c, x, y, w, text, bg=TEAL, fg=WHITE, fontsize=9):
    c.setFillColor(bg)
    c.rect(x, y, w, 0.22*inch, fill=1, stroke=0)
    c.setFillColor(fg)
    c.setFont("Helvetica-Bold", fontsize)
    c.drawString(x + 0.08*inch, y + 0.05*inch, text)

def bullet(c, x, y, text, fontsize=7.5, color=DARK_GRAY, bold_prefix=None):
    c.setFillColor(TEAL)
    c.circle(x + 0.04*inch, y + 0.055*inch, 0.025*inch, fill=1, stroke=0)
    c.setFillColor(color)
    if bold_prefix:
        c.setFont("Helvetica-Bold", fontsize)
        bw = c.stringWidth(bold_prefix, "Helvetica-Bold", fontsize)
        c.drawString(x + 0.13*inch, y + 0.03*inch, bold_prefix)
        c.setFont("Helvetica", fontsize)
        c.drawString(x + 0.13*inch + bw, y + 0.03*inch, text)
    else:
        c.setFont("Helvetica", fontsize)
        c.drawString(x + 0.13*inch, y + 0.03*inch, text)

def small_text(c, x, y, text, fontsize=7, color=DARK_GRAY, bold=False):
    c.setFillColor(color)
    c.setFont("Helvetica-Bold" if bold else "Helvetica", fontsize)
    c.drawString(x, y, text)

def tag(c, x, y, text, bg=RED_ACCENT, fg=WHITE, fontsize=6.5):
    tw = c.stringWidth(text, "Helvetica-Bold", fontsize)
    pad = 0.05*inch
    c.setFillColor(bg)
    c.roundRect(x, y, tw + 2*pad, 0.15*inch, 0.03*inch, fill=1, stroke=0)
    c.setFillColor(fg)
    c.setFont("Helvetica-Bold", fontsize)
    c.drawString(x + pad, y + 0.025*inch, text)

def divider(c, x, y, w, color=MID_GRAY):
    c.setStrokeColor(color)
    c.setLineWidth(0.4)
    c.line(x, y, x+w, y)

def box_outline(c, x, y, w, h, color=MID_GRAY):
    c.setStrokeColor(color)
    c.setLineWidth(0.5)
    c.roundRect(x, y, w, h, 0.05*inch, fill=0, stroke=1)

# ─────────────────────────────────────────────────────────────────────────────
# PAGE 1  —  FRONT
# ─────────────────────────────────────────────────────────────────────────────
def draw_front(c):
    # Background
    c.setFillColor(LIGHT_GRAY)
    c.rect(0, 0, W, H, fill=1, stroke=0)

    # Top banner
    c.setFillColor(NAVY)
    c.rect(0, H - 0.75*inch, W, 0.75*inch, fill=1, stroke=0)
    c.setFillColor(WHITE)
    c.setFont("Helvetica-Bold", 15)
    c.drawCentredString(W/2, H - 0.38*inch, "🫀  EKG Quick Reference Card  —  Advanced HF & Transplant")
    c.setFont("Helvetica", 8)
    c.setFillColor(LIGHT_TEAL)
    c.drawCentredString(W/2, H - 0.60*inch, "FRONT  |  Systematic Approach · Intervals · Key Patterns  |  For APN Use")

    # Accent stripe
    c.setFillColor(TEAL)
    c.rect(0, H - 0.78*inch, W, 0.04*inch, fill=1, stroke=0)

    # ── COL LEFT  x=0.35  w=3.55 ────────────────────────────────────────────
    LX = 0.35*inch
    LW = 3.55*inch

    # 1. SYSTEMATIC APPROACH
    cy = H - 1.08*inch
    section_header(c, LX, cy, LW, "STEP-BY-STEP SYSTEMATIC APPROACH")
    cy -= 0.02*inch

    steps = [
        ("1  RATE",      "Count R-R big boxes → 300 ÷ # boxes = rate  |  Normal: 60–100 bpm"),
        ("2  RHYTHM",    "Regular R-R? P before every QRS? → Sinus if yes"),
        ("3  AXIS",      "Lead I + aVF both upright = normal (−30° to +90°)"),
        ("4  INTERVALS", "Measure PR, QRS, QTc (see table below)"),
        ("5  MORPHOLOGY","P shape, Q waves, ST segments, T waves"),
    ]
    row_bg = [LIGHT_TEAL, WHITE, LIGHT_TEAL, WHITE, LIGHT_TEAL]
    for i, (label, detail) in enumerate(steps):
        cy -= 0.23*inch
        c.setFillColor(row_bg[i])
        c.rect(LX, cy, LW, 0.22*inch, fill=1, stroke=0)
        c.setFillColor(NAVY)
        c.setFont("Helvetica-Bold", 7.5)
        c.drawString(LX + 0.07*inch, cy + 0.07*inch, label)
        lw = c.stringWidth(label, "Helvetica-Bold", 7.5)
        c.setFillColor(DARK_GRAY)
        c.setFont("Helvetica", 7.2)
        c.drawString(LX + 0.12*inch + lw, cy + 0.07*inch, detail)

    # 2. NORMAL INTERVALS TABLE
    cy -= 0.3*inch
    section_header(c, LX, cy, LW, "NORMAL INTERVALS")
    cy -= 0.22*inch

    rows = [
        ["Interval", "Normal Range", "Clinical Pearl"],
        ["PR interval", "0.12 – 0.20 sec\n(3–5 sm boxes)", "Prolonged = heart block\n(common post-transplant)"],
        ["QRS duration", "< 0.12 sec\n(< 3 sm boxes)", "Wide QRS → BBB or VT\nLBBB + EF≤35% → CRT?"],
        ["QTc", "♂ < 0.44 s\n♀ < 0.46 s", "Many HF drugs prolong QT\nAmiodarone, azoles, ABX"],
    ]

    col_widths = [0.85*inch, 1.15*inch, 1.55*inch]
    table = Table(rows, colWidths=col_widths, rowHeights=[0.2*inch, 0.36*inch, 0.36*inch, 0.36*inch])
    table.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,0), NAVY),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,0), 7.5),
        ("BACKGROUND",   (0,1), (-1,1), LIGHT_TEAL),
        ("BACKGROUND",   (0,2), (-1,2), WHITE),
        ("BACKGROUND",   (0,3), (-1,3), LIGHT_TEAL),
        ("FONTNAME",     (0,1), (-1,-1), "Helvetica"),
        ("FONTSIZE",     (0,1), (-1,-1), 7),
        ("FONTNAME",     (0,1), (0,-1), "Helvetica-Bold"),
        ("TEXTCOLOR",    (0,1), (0,-1), NAVY),
        ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
        ("ALIGN",        (0,0), (-1,-1), "LEFT"),
        ("LEFTPADDING",  (0,0), (-1,-1), 4),
        ("RIGHTPADDING", (0,0), (-1,-1), 3),
        ("GRID",         (0,0), (-1,-1), 0.4, MID_GRAY),
        ("ROWBACKGROUNDS", (0,0), (-1,-1), [None]),
    ]))
    table.wrapOn(c, LW, 2*inch)
    table.drawOn(c, LX, cy - 1.08*inch)
    cy -= 1.15*inch

    # 3. RATE QUICK CALC BOX
    cy -= 0.3*inch
    section_header(c, LX, cy, LW, "HEART RATE QUICK CALC")
    cy -= 0.02*inch
    rate_data = [
        ["# Big Boxes", "1", "2", "3", "4", "5", "6"],
        ["Heart Rate",  "300","150","100","75","60","50"],
    ]
    rt = Table(rate_data, colWidths=[1.05*inch] + [0.41*inch]*6, rowHeights=[0.18*inch, 0.18*inch])
    rt.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,0), TEAL),
        ("TEXTCOLOR",   (0,0), (-1,0), WHITE),
        ("FONTNAME",    (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",    (0,0), (-1,-1), 7.5),
        ("BACKGROUND",  (0,1), (-1,1), LIGHT_TEAL),
        ("FONTNAME",    (0,1), (-1,1), "Helvetica-Bold"),
        ("TEXTCOLOR",   (0,1), (-1,1), NAVY),
        ("ALIGN",       (0,0), (-1,-1), "CENTER"),
        ("VALIGN",      (0,0), (-1,-1), "MIDDLE"),
        ("GRID",        (0,0), (-1,-1), 0.4, MID_GRAY),
    ]))
    rt.wrapOn(c, LW, 0.5*inch)
    cy -= 0.38*inch
    rt.drawOn(c, LX, cy)

    # ── COL RIGHT  x=4.15  w=3.95 ───────────────────────────────────────────
    RX = 4.15*inch
    RW = 4.00*inch

    ry = H - 1.08*inch
    section_header(c, RX, ry, RW, "KEY EKG PATTERNS")

    patterns = [
        {
            "title": "LBBB  —  Left Bundle Branch Block",
            "color": NAVY,
            "tag": "CRT CANDIDATE?",
            "tag_bg": AMBER,
            "bullets": [
                ("QRS > 0.12 sec", " (≥ 3 small boxes)"),
                ("V5–V6:", " broad notched 'M' shape  |  V1: deep S wave"),
                ("NEW LBBB + chest pain", " → treat as STEMI"),
                ("EF ≤ 35% + LBBB + NYHA II–IV", " → refer for CRT"),
            ]
        },
        {
            "title": "RBBB  —  Right Bundle Branch Block",
            "color": TEAL,
            "tag": "NORMAL POST-TRANSPLANT",
            "tag_bg": GREEN,
            "bullets": [
                ("V1–V2:", " 'RSR\\'' (rabbit ears) pattern"),
                ("V5–V6:", " wide slurred S wave"),
                ("Incomplete RBBB post-transplant", " = expected, not pathologic"),
                ("Complete RBBB:", " usually benign; evaluate in context"),
            ]
        },
        {
            "title": "VENTRICULAR TACHYCARDIA (VT)",
            "color": RED_ACCENT,
            "tag": "HIGH RISK",
            "tag_bg": RED_ACCENT,
            "bullets": [
                ("Wide complex tach:", " QRS > 0.12, rate > 100 bpm"),
                ("NO P waves before QRS", " (or AV dissociation)"),
                ("Fusion beats", " at start confirm VT"),
                ("ICD indicated", " if EF ≤ 35% (primary prevention)"),
            ]
        },
        {
            "title": "ATRIAL FIBRILLATION",
            "color": colors.HexColor("#6C3483"),
            "tag": "COMMON IN HF",
            "tag_bg": colors.HexColor("#6C3483"),
            "bullets": [
                ("Irregularly irregular", " R-R intervals"),
                ("No clear P waves,", " fibrillatory baseline"),
                ("Rate control vs. rhythm control", " based on HF severity"),
                ("Ivabradine does NOT work", " in A-fib (sinus rhythm only)"),
            ]
        },
        {
            "title": "HEART BLOCK",
            "color": colors.HexColor("#784212"),
            "tag": "CHECK POST-TRANSPLANT",
            "tag_bg": AMBER,
            "bullets": [
                ("1°:", " PR > 0.20 sec, every P conducts"),
                ("2° Mobitz I:", " progressive PR lengthening → dropped beat"),
                ("2° Mobitz II:", " fixed PR, sudden dropped QRS → pacemaker likely"),
                ("3° (complete):", " no P-QRS relationship → urgent pacemaker"),
            ]
        },
    ]

    ry -= 0.02*inch
    for pat in patterns:
        ry -= 0.23*inch
        # Pattern title bar
        c.setFillColor(pat["color"])
        c.rect(RX, ry, RW, 0.22*inch, fill=1, stroke=0)
        c.setFillColor(WHITE)
        c.setFont("Helvetica-Bold", 8)
        c.drawString(RX + 0.08*inch, ry + 0.06*inch, pat["title"])
        # Tag
        tag(c, RX + RW - c.stringWidth(pat["tag"], "Helvetica-Bold", 6.5) - 0.18*inch,
            ry + 0.035*inch, pat["tag"], bg=pat["tag_bg"])
        ry -= 0.01*inch
        for b_bold, b_rest in pat["bullets"]:
            ry -= 0.135*inch
            bullet(c, RX + 0.04*inch, ry, b_rest, fontsize=7, bold_prefix=b_bold)
        ry -= 0.03*inch

    # ── BOTTOM FULL-WIDTH BAR: TRANSPLANT EKG ALERT ──────────────────────────
    alert_y = 0.52*inch
    c.setFillColor(colors.HexColor("#FEF9E7"))
    c.roundRect(0.35*inch, alert_y, W - 0.7*inch, 0.42*inch, 0.06*inch, fill=1, stroke=0)
    c.setStrokeColor(AMBER)
    c.setLineWidth(1.2)
    c.roundRect(0.35*inch, alert_y, W - 0.7*inch, 0.42*inch, 0.06*inch, fill=0, stroke=1)
    c.setFillColor(AMBER)
    c.setFont("Helvetica-Bold", 8)
    c.drawString(0.5*inch, alert_y + 0.27*inch, "⚠  TRANSPLANT HEART ALERTS:")
    c.setFont("Helvetica", 7.2)
    c.setFillColor(DARK_GRAY)
    alerts = [
        "Resting HR 95–110 bpm (no vagal tone) → normal early post-Tx",
        "Incomplete RBBB → expected finding",
        "Q waves / ST elevation → SIGNIFICANT (silent MI — no chest pain!)",
        "Atropine / Glycopyrrolate → USELESS (vagus nerve is cut)",
        "Adenosine → use HALF dose (↑ AV block risk)",
    ]
    ax = 0.5*inch
    for i, a in enumerate(alerts):
        col = ax + (i % 3) * (2.6*inch) if i < 3 else ax + ((i-3) % 3) * (3.9*inch)
        row_y = alert_y + 0.22*inch if i < 3 else alert_y + 0.06*inch
        c.setFillColor(RED_ACCENT)
        c.circle(col + 0.04*inch, row_y + 0.055*inch, 0.022*inch, fill=1, stroke=0)
        c.setFillColor(DARK_GRAY)
        c.drawString(col + 0.12*inch, row_y + 0.03*inch, a)

    # Footer
    c.setFillColor(NAVY)
    c.rect(0, 0, W, 0.35*inch, fill=1, stroke=0)
    c.setFillColor(WHITE)
    c.setFont("Helvetica", 6.5)
    c.drawCentredString(W/2, 0.13*inch,
        "Sources: Braunwald's Heart Disease 11e · Goldman-Cecil Medicine · Rosen's Emergency Medicine  |  FRONT — See reverse for Transplant EKG & Arrhythmia Drug Guide")


# ─────────────────────────────────────────────────────────────────────────────
# PAGE 2  —  BACK
# ─────────────────────────────────────────────────────────────────────────────
def draw_back(c):
    # Background
    c.setFillColor(LIGHT_GRAY)
    c.rect(0, 0, W, H, fill=1, stroke=0)

    # Top banner
    c.setFillColor(TEAL)
    c.rect(0, H - 0.75*inch, W, 0.75*inch, fill=1, stroke=0)
    c.setFillColor(WHITE)
    c.setFont("Helvetica-Bold", 15)
    c.drawCentredString(W/2, H - 0.38*inch, "🫀  EKG Quick Reference Card  —  Advanced HF & Transplant")
    c.setFont("Helvetica", 8)
    c.setFillColor(LIGHT_TEAL)
    c.drawCentredString(W/2, H - 0.60*inch, "BACK  |  ST / T-Wave Changes · HF EKG Findings · Arrhythmia Drug Guide · CAV")
    c.setFillColor(NAVY)
    c.rect(0, H - 0.78*inch, W, 0.04*inch, fill=1, stroke=0)

    # ── LEFT COLUMN ──────────────────────────────────────────────────────────
    LX = 0.35*inch
    LW = 3.55*inch
    cy = H - 1.1*inch

    # ST / T WAVE CHANGES
    section_header(c, LX, cy, LW, "ST SEGMENT & T-WAVE CHANGES")
    cy -= 0.03*inch

    st_rows = [
        ["Finding", "Think About", "Action"],
        ["ST elevation\n(≥1 mm, ≥2 leads)", "STEMI / Pericarditis\nIn Tx pt: CAV, silent MI", "Urgent cardiology consult\nDo NOT delay for biopsy"],
        ["ST depression", "NSTEMI / Ischemia\nDigoxin effect (scooped)", "Troponin, cardiology"],
        ["Diffuse saddle-shaped\nST elevation", "Pericarditis", "CRP, echo, NSAIDs\n(if not on anticoag)"],
        ["Peaked T waves", "Hyperkalemia ⚠", "STAT K⁺ level → treat"],
        ["Flat/inverted T waves", "Ischemia, LVH,\nelectrolyte imbalance", "Clinical correlation"],
        ["Prolonged QTc\n(men >0.44, women >0.46)", "Drug toxicity, ↓Mg, ↓K\nAmiodarone, azoles", "Review meds, lytes\nReduce offending drug"],
    ]
    st_col_w = [1.1*inch, 1.35*inch, 1.1*inch]
    st_row_h = [0.19*inch] + [0.39*inch]*6
    st = Table(st_rows, colWidths=st_col_w, rowHeights=st_row_h)
    st.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,0), NAVY),
        ("TEXTCOLOR",   (0,0), (-1,0), WHITE),
        ("FONTNAME",    (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",    (0,0), (-1,0), 7.5),
        ("FONTNAME",    (0,1), (-1,-1), "Helvetica"),
        ("FONTNAME",    (0,1), (0,-1), "Helvetica-Bold"),
        ("TEXTCOLOR",   (0,1), (0,-1), NAVY),
        ("FONTSIZE",    (0,1), (-1,-1), 6.8),
        ("BACKGROUND",  (0,1), (-1,1), LIGHT_TEAL),
        ("BACKGROUND",  (0,2), (-1,2), WHITE),
        ("BACKGROUND",  (0,3), (-1,3), LIGHT_TEAL),
        ("BACKGROUND",  (0,4), (-1,4), colors.HexColor("#FADBD8")),
        ("BACKGROUND",  (0,5), (-1,5), WHITE),
        ("BACKGROUND",  (0,6), (-1,6), colors.HexColor("#FEF9E7")),
        ("VALIGN",      (0,0), (-1,-1), "MIDDLE"),
        ("ALIGN",       (0,0), (-1,-1), "LEFT"),
        ("LEFTPADDING", (0,0), (-1,-1), 4),
        ("GRID",        (0,0), (-1,-1), 0.4, MID_GRAY),
    ]))
    st.wrapOn(c, LW, 3*inch)
    cy -= 2.73*inch
    st.drawOn(c, LX, cy)

    # HF-SPECIFIC EKG FINDINGS
    cy -= 0.32*inch
    section_header(c, LX, cy, LW, "HF-SPECIFIC EKG FINDINGS")
    cy -= 0.03*inch

    hf_findings = [
        ("Low voltage throughout all leads", "Cardiac amyloidosis (ATTR-CM)"),
        ("LBBB  + EF ≤ 35%", "CRT candidate — refer"),
        ("QRS > 150 ms + LBBB", "Strongest CRT benefit"),
        ("Q waves in transplant patient", "Silent MI → CAV workup (angiogram)"),
        ("Sinus tach (HR 95–110)", "Normal early post-transplant (denervation)"),
        ("Abnormal HRV (HR variability)", "Poor prognosis marker in dilated CMP"),
        ("Nonsustained VT (NSVT) on monitor", "EF ≤ 35% → ICD evaluation"),
    ]

    for i, (finding, meaning) in enumerate(hf_findings):
        cy -= 0.19*inch
        bg = LIGHT_TEAL if i % 2 == 0 else WHITE
        c.setFillColor(bg)
        c.rect(LX, cy, LW, 0.18*inch, fill=1, stroke=0)
        c.setFillColor(NAVY)
        c.setFont("Helvetica-Bold", 7)
        c.drawString(LX + 0.07*inch, cy + 0.05*inch, finding)
        fw = c.stringWidth(finding, "Helvetica-Bold", 7)
        c.setFillColor(colors.HexColor("#555555"))
        c.setFont("Helvetica", 7)
        c.drawString(LX + 0.1*inch + fw, cy + 0.05*inch, "  →  " + meaning)

    # ── RIGHT COLUMN ─────────────────────────────────────────────────────────
    RX = 4.15*inch
    RW = 4.00*inch
    ry = H - 1.1*inch

    # ARRHYTHMIA DRUG GUIDE
    section_header(c, RX, ry, RW, "ARRHYTHMIA DRUG GUIDE  —  HF / TRANSPLANT")
    ry -= 0.03*inch

    drug_rows = [
        ["Arrhythmia", "First-Line Rx", "HF / Transplant Notes"],
        ["A-fib\n(rate control)", "Beta-blocker\nDiltiazem (non-HFrEF)", "Avoid diltiazem if EF↓\nDigoxin adjunct if symptomatic"],
        ["A-fib\n(rhythm control)", "Amiodarone\nDofetilide", "Amiodarone: ↑ CNI levels in Tx\nDofetilide: QTc monitoring"],
        ["VT (stable)\nVT storm", "Amiodarone IV\nBeta-blocker IV", "ICD + antiarrhythmic combo\nRule out ischemia / lytes"],
        ["VF / pulseless VT", "Defibrillation 200J\nAmiodarone 300 mg IV", "Standard ACLS\nNo special Tx rules"],
        ["SVT\n(transplant heart)", "Adenosine ½ dose\nBeta-blocker / Diltiazem", "Atropine = INEFFECTIVE\nGlycopyrrolate = INEFFECTIVE"],
        ["Bradycardia\n(transplant heart)", "Isoproterenol / Dopamine\nPacing if refractory", "Atropine = INEFFECTIVE\nDenervated — no vagal response"],
        ["Torsades de Pointes", "Mg sulfate 2g IV\nStop QT-prolonging drugs", "Correct K⁺ & Mg²⁺\nTemporary pacing if refractory"],
    ]
    dr_col_w = [1.1*inch, 1.3*inch, 1.6*inch]
    dr_row_h = [0.19*inch] + [0.42*inch]*7
    dr = Table(drug_rows, colWidths=dr_col_w, rowHeights=dr_row_h)
    dr.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,0), NAVY),
        ("TEXTCOLOR",   (0,0), (-1,0), WHITE),
        ("FONTNAME",    (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",    (0,0), (-1,0), 7.5),
        ("FONTNAME",    (0,1), (-1,-1), "Helvetica"),
        ("FONTNAME",    (0,1), (0,-1), "Helvetica-Bold"),
        ("TEXTCOLOR",   (0,1), (0,-1), NAVY),
        ("FONTSIZE",    (0,1), (-1,-1), 7),
        ("BACKGROUND",  (0,1), (-1,1), LIGHT_TEAL),
        ("BACKGROUND",  (0,2), (-1,2), WHITE),
        ("BACKGROUND",  (0,3), (-1,3), LIGHT_TEAL),
        ("BACKGROUND",  (0,4), (-1,4), colors.HexColor("#FADBD8")),
        ("BACKGROUND",  (0,5), (-1,5), colors.HexColor("#FEF9E7")),
        ("BACKGROUND",  (0,6), (-1,6), colors.HexColor("#FEF9E7")),
        ("BACKGROUND",  (0,7), (-1,7), WHITE),
        ("VALIGN",      (0,0), (-1,-1), "MIDDLE"),
        ("ALIGN",       (0,0), (-1,-1), "LEFT"),
        ("LEFTPADDING", (0,0), (-1,-1), 4),
        ("GRID",        (0,0), (-1,-1), 0.4, MID_GRAY),
    ]))
    dr.wrapOn(c, RW, 4*inch)
    ry -= 3.38*inch
    dr.drawOn(c, RX, ry)

    # CAV BOX
    ry -= 0.33*inch
    c.setFillColor(colors.HexColor("#FADBD8"))
    c.roundRect(RX, ry - 1.25*inch, RW, 1.28*inch, 0.06*inch, fill=1, stroke=0)
    c.setStrokeColor(RED_ACCENT)
    c.setLineWidth(1)
    c.roundRect(RX, ry - 1.25*inch, RW, 1.28*inch, 0.06*inch, fill=0, stroke=1)

    c.setFillColor(RED_ACCENT)
    c.rect(RX, ry - 0.26*inch, RW, 0.28*inch, fill=1, stroke=0)
    c.setFillColor(WHITE)
    c.setFont("Helvetica-Bold", 8.5)
    c.drawCentredString(RX + RW/2, ry - 0.19*inch, "CARDIAC ALLOGRAFT VASCULOPATHY (CAV)")

    cav_points = [
        ("What:", "Diffuse concentric coronary narrowing — the transplant's \"CAD\""),
        ("Silent:", "No angina (denervated heart) → presents as SCD or silent MI"),
        ("Diagnose:", "Coronary angiography (gold std); IVUS detects early CAV"),
        ("EKG clue:", "New Q waves or ST elevation in transplant patient"),
        ("Prevent:", "Statin therapy for ALL transplant patients; BP / lipid control"),
        ("Treat:", "Sirolimus/everolimus may slow; severe → retransplantation"),
    ]
    cav_y = ry - 0.28*inch
    for label, detail in cav_points:
        cav_y -= 0.165*inch
        c.setFillColor(RED_ACCENT)
        c.setFont("Helvetica-Bold", 7)
        c.drawString(RX + 0.1*inch, cav_y, label)
        lw = c.stringWidth(label, "Helvetica-Bold", 7)
        c.setFillColor(DARK_GRAY)
        c.setFont("Helvetica", 7)
        c.drawString(RX + 0.13*inch + lw, cav_y, "  " + detail)

    # NYHA / ICD INDICATIONS MINI BOX — bottom left
    bly = 0.52*inch
    c.setFillColor(LIGHT_TEAL)
    c.roundRect(LX, bly, LW, 0.72*inch, 0.05*inch, fill=1, stroke=0)
    c.setStrokeColor(TEAL)
    c.setLineWidth(0.8)
    c.roundRect(LX, bly, LW, 0.72*inch, 0.05*inch, fill=0, stroke=1)
    c.setFillColor(TEAL)
    c.setFont("Helvetica-Bold", 8)
    c.drawString(LX + 0.1*inch, bly + 0.54*inch, "ICD PRIMARY PREVENTION CRITERIA  (ALL 3 must be met):")
    icd_items = [
        "① EF ≤ 35%  (despite ≥ 3 months optimal GDMT)",
        "② NYHA functional class II or III",
        "③ Life expectancy > 1 year with good functional status",
    ]
    c.setFont("Helvetica", 7.3)
    c.setFillColor(DARK_GRAY)
    for j, item in enumerate(icd_items):
        c.drawString(LX + 0.15*inch, bly + 0.36*inch - j*0.15*inch, item)

    # Bottom right mini-box: electrolyte EKG
    brx = RX
    c.setFillColor(colors.HexColor("#EBF5FB"))
    c.roundRect(brx, bly, RW, 0.72*inch, 0.05*inch, fill=1, stroke=0)
    c.setStrokeColor(TEAL)
    c.setLineWidth(0.8)
    c.roundRect(brx, bly, RW, 0.72*inch, 0.05*inch, fill=0, stroke=1)
    c.setFillColor(TEAL)
    c.setFont("Helvetica-Bold", 8)
    c.drawString(brx + 0.1*inch, bly + 0.54*inch, "ELECTROLYTE EKG CHANGES  (common in HF/diuretic use):")
    elec = [
        "Hyperkalemia: Peaked T waves → wide QRS → sine wave → VF",
        "Hypokalemia:  Flat T waves, U waves (after T wave), QTc prolongation",
        "Hypomagnesemia: Torsades de Pointes, ↑ risk with ↓K⁺",
    ]
    c.setFont("Helvetica", 7.1)
    c.setFillColor(DARK_GRAY)
    for j, item in enumerate(elec):
        c.drawString(brx + 0.15*inch, bly + 0.36*inch - j*0.155*inch, item)

    # Footer
    c.setFillColor(NAVY)
    c.rect(0, 0, W, 0.35*inch, fill=1, stroke=0)
    c.setFillColor(WHITE)
    c.setFont("Helvetica", 6.5)
    c.drawCentredString(W/2, 0.13*inch,
        "Sources: Braunwald's Heart Disease 11e · Goldman-Cecil Medicine · Rosen's Emergency Medicine  |  BACK — See front for Systematic Approach & Interval Guide")


# ─────────────────────────────────────────────────────────────────────────────
# BUILD
# ─────────────────────────────────────────────────────────────────────────────
OUTPUT = "/home/daytona/workspace/ekgcard/EKG_Quick_Reference_Card.pdf"

c = canvas.Canvas(OUTPUT, pagesize=letter)
c.setTitle("EKG Quick Reference Card — Advanced HF & Transplant APN")
c.setAuthor("Orris Medical AI")
c.setSubject("EKG Quick Reference for Advanced Heart Failure and Transplant APN")

draw_front(c)
c.showPage()
draw_back(c)
c.save()

print(f"PDF created: {OUTPUT}")
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