Antihypertensive Drugs: Which Drug for Which Condition

from reportlab.lib.pagesizes import A4, landscape
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import mm, cm
from reportlab.platypus import (
    SimpleDocTemplate, Table, TableStyle, Paragraph,
    Spacer, HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.platypus import PageBreak

OUTPUT = "/home/daytona/workspace/bp-chart/BP_Medications_QuickRef.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
NAVY      = colors.HexColor("#1a3a5c")
TEAL      = colors.HexColor("#1a7a8a")
AMBER     = colors.HexColor("#d4830a")
RED       = colors.HexColor("#c0392b")
GREEN     = colors.HexColor("#1e7d44")
LTBLUE    = colors.HexColor("#dceef5")
LTTEAL    = colors.HexColor("#d4f0f0")
LTAMBER   = colors.HexColor("#fdf3dc")
LTRED     = colors.HexColor("#fde8e6")
LTGREEN   = colors.HexColor("#e6f5ec")
GREY1     = colors.HexColor("#f2f4f6")
GREY2     = colors.HexColor("#dce0e5")
WHITE     = colors.white
BLACK     = colors.black

# ── Styles ──────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

title_style = ParagraphStyle(
    "Title", fontSize=20, textColor=WHITE, fontName="Helvetica-Bold",
    alignment=TA_CENTER, spaceAfter=2
)
subtitle_style = ParagraphStyle(
    "Subtitle", fontSize=9, textColor=colors.HexColor("#cce0ee"),
    fontName="Helvetica", alignment=TA_CENTER, spaceAfter=0
)
section_style = ParagraphStyle(
    "Section", fontSize=11, textColor=WHITE, fontName="Helvetica-Bold",
    alignment=TA_CENTER
)
cell_body = ParagraphStyle(
    "CellBody", fontSize=7.5, fontName="Helvetica", leading=10,
    alignment=TA_LEFT
)
cell_bold = ParagraphStyle(
    "CellBold", fontSize=7.5, fontName="Helvetica-Bold", leading=10,
    alignment=TA_LEFT
)
cell_center = ParagraphStyle(
    "CellCenter", fontSize=7.5, fontName="Helvetica", leading=10,
    alignment=TA_CENTER
)
cell_center_bold = ParagraphStyle(
    "CellCenterBold", fontSize=8, fontName="Helvetica-Bold", leading=11,
    alignment=TA_CENTER
)
small_note = ParagraphStyle(
    "SmallNote", fontSize=6.5, fontName="Helvetica-Oblique", leading=9,
    textColor=colors.HexColor("#555555"), alignment=TA_CENTER
)

# ── Helper ───────────────────────────────────────────────────────────────────
def p(text, style=cell_body):
    return Paragraph(text, style)

def tick(yes=True):
    return p("✔" if yes else "—", cell_center)

# ─────────────────────────────────────────────────────────────────────────────
# PAGE 1  –  Compelling Indications + Drug Classes
# ─────────────────────────────────────────────────────────────────────────────

def build_page1():
    elems = []

    # ── Header banner ─────────────────────────────────────────────────────
    header_data = [[
        p("BP MEDICATIONS  |  QUICK REFERENCE CHART", title_style)
    ]]
    header_tbl = Table(header_data, colWidths=[267*mm])
    header_tbl.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), NAVY),
        ("TOPPADDING",  (0,0), (-1,-1), 10),
        ("BOTTOMPADDING",(0,0),(-1,-1), 6),
        ("LEFTPADDING", (0,0), (-1,-1), 6),
        ("RIGHTPADDING",(0,0), (-1,-1), 6),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 6),
    ]))
    elems.append(header_tbl)
    elems.append(Spacer(1, 4*mm))

    # ── SECTION 1: Compelling Indications ─────────────────────────────────
    sec1_hdr = Table([[p("COMPELLING INDICATIONS  (JNC 7 / ACC-AHA 2018)", section_style)]],
                     colWidths=[267*mm])
    sec1_hdr.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), TEAL),
        ("TOPPADDING",  (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 4),
    ]))
    elems.append(sec1_hdr)
    elems.append(Spacer(1, 2*mm))

    col_w = [44, 30, 30, 36, 30, 30, 30, 37]  # mm
    col_w_pts = [x*mm for x in col_w]

    ci_header = [
        p("Condition", cell_center_bold),
        p("Diuretic\n(Thiazide)", cell_center_bold),
        p("Beta-\nBlocker", cell_center_bold),
        p("ACE\nInhibitor", cell_center_bold),
        p("ARB", cell_center_bold),
        p("CCB", cell_center_bold),
        p("MRA\n(Spiro)", cell_center_bold),
        p("Notes", cell_center_bold),
    ]

    ci_data = [
        ci_header,
        [p("Heart Failure (HFrEF)", cell_bold), tick(), tick(), tick(), tick(), tick(False),
         tick(), p("Avoid verapamil/diltiazem", cell_body)],
        [p("Post-MI", cell_bold), tick(False), tick(), tick(), tick(False), tick(False),
         tick(), p("Beta-blocker within 24h", cell_body)],
        [p("High CAD Risk / Angina", cell_bold), tick(), tick(), tick(), tick(False), tick(),
         tick(False), p("CCB: prefer amlodipine", cell_body)],
        [p("Diabetes Mellitus", cell_bold), tick(), tick(), tick(), tick(), tick(),
         tick(False), p("ACEi/ARB renoprotective", cell_body)],
        [p("CKD / Proteinuria", cell_bold), tick(False), tick(False), tick(), tick(),
         tick(False), tick(False), p("ACEi or ARB first-line", cell_body)],
        [p("Stroke Prevention\n(Recurrent)", cell_bold), tick(), tick(False), tick(),
         tick(False), tick(False), tick(False), p("Thiazide + ACEi combo", cell_body)],
        [p("Atrial Fibrillation\n(Rate control)", cell_bold), tick(False), tick(), tick(False),
         tick(False), p("✔ non-DHP\n(diltiazem)", cell_center), tick(False),
         p("Avoid DHP CCBs alone", cell_body)],
        [p("Pregnancy", cell_bold), tick(False), p("✔ Labetalol\nonly", cell_center),
         tick(False), tick(False), p("✔ Nifedipine\n(long-acting)", cell_center),
         tick(False), p("Methyldopa also safe", cell_body)],
        [p("BPH", cell_bold), tick(False), tick(False), tick(False), tick(False), tick(False),
         tick(False), p("Alpha-blocker (doxazosin)", cell_body)],
        [p("Phaeochromocytoma", cell_bold), tick(False), p("✔ After\nalpha-block", cell_center),
         tick(False), tick(False), tick(False), tick(False),
         p("Alpha-blocker (phentolamine) FIRST", cell_body)],
    ]

    ci_tbl = Table(ci_data, colWidths=col_w_pts, repeatRows=1)
    ci_style = [
        # Header row
        ("BACKGROUND",   (0,0), (-1,0), NAVY),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,0), 8),
        ("ALIGN",        (0,0), (-1,0), "CENTER"),
        ("VALIGN",       (0,0), (-1,-1),"MIDDLE"),
        ("TOPPADDING",   (0,0), (-1,-1), 4),
        ("BOTTOMPADDING",(0,0), (-1,-1), 4),
        ("LEFTPADDING",  (0,0), (-1,-1), 4),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("GRID",         (0,0), (-1,-1), 0.4, GREY2),
        ("ROWBACKGROUNDS",(0,1),(-1,-1),[WHITE, GREY1]),
        # Condition column highlight
        ("BACKGROUND",   (0,1), (0,-1), LTBLUE),
        ("FONTNAME",     (0,1), (0,-1), "Helvetica-Bold"),
    ]
    ci_tbl.setStyle(TableStyle(ci_style))
    elems.append(ci_tbl)
    elems.append(Spacer(1, 4*mm))

    # ── SECTION 2: Drug Class Summary ─────────────────────────────────────
    sec2_hdr = Table([[p("DRUG CLASS SUMMARY  –  Mechanisms, Side Effects & Key Indications", section_style)]],
                     colWidths=[267*mm])
    sec2_hdr.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), colors.HexColor("#1e5e3e")),
        ("TOPPADDING",  (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 4),
    ]))
    elems.append(sec2_hdr)
    elems.append(Spacer(1, 2*mm))

    dc_col_w = [45, 38, 55, 55, 74]  # mm
    dc_col_w_pts = [x*mm for x in dc_col_w]

    dc_header = [
        p("Drug Class", cell_center_bold),
        p("Examples", cell_center_bold),
        p("Mechanism", cell_center_bold),
        p("Side Effects", cell_center_bold),
        p("Key Indications / Notes", cell_center_bold),
    ]

    dc_rows = [
        ["Thiazide/Thiazide-like\nDiuretics",
         "HCTZ, Chlorthalidone\nIndapamide",
         "Inhibit Na-Cl cotransporter\n(distal convoluted tubule)",
         "Hypokalemia, hyponatremia,\nhyperuricemia, hyperglycemia,\ndyslipidemia",
         "First-line uncomplicated HTN;\nheart failure; CAD risk;\nstroke prevention.\nChlorothalidone preferred over HCTZ"],
        ["Loop Diuretics",
         "Furosemide\nBumetanide",
         "Inhibit Na-K-2Cl cotransporter\n(thick ascending limb)",
         "Hypokalemia, ototoxicity,\ndehydration",
         "HTN + volume overload;\nheart failure;\nCKD with GFR <30 (thiazides lose efficacy)"],
        ["ACE Inhibitors",
         "Ramipril, Lisinopril\nEnalapril, Perindopril",
         "Block Ang I → Ang II conversion\n(bradykinin accumulation)",
         "Dry cough (10-15%),\nhyperkalemia, ↑creatinine,\nangioedema (rare)",
         "Heart failure, post-MI, CKD with\nproteinuria, diabetes, stroke.\nAVOID: pregnancy, bilateral RAS"],
        ["Angiotensin Receptor\nBlockers (ARBs)",
         "Losartan, Valsartan\nTelmisartan, Irbesartan",
         "Block Ang II at AT1 receptor\n(no bradykinin accumulation)",
         "Similar to ACEi;\nNO cough; rare angioedema",
         "Same as ACEi — preferred when\nACEi cough intolerable.\nAVOID: pregnancy, bilateral RAS"],
        ["Dihydropyridine\nCCBs (DHP)",
         "Amlodipine\nNifedipine (SR)\nFelodipine",
         "Block L-type Ca²⁺ channels\n→ vasodilation",
         "Peripheral edema, flushing,\ngingival hyperplasia",
         "Uncomplicated HTN, elderly,\nisolated systolic HTN, angina,\nCKD, black patients, diabetes"],
        ["Non-DHP CCBs",
         "Diltiazem\nVerapamil",
         "Block L-type Ca²⁺ channels\n+ AV nodal depression",
         "Bradycardia, AV block;\nverapamil: constipation",
         "HTN + angina + AF (rate control).\nAVOID: HFrEF, AV block,\nwith beta-blockers"],
        ["Beta-Blockers",
         "Metoprolol, Atenolol\nCarvedilol, Bisoprolol\nLabetalol (IV/oral)",
         "Block β1 (and β2 if non-selective)\nadrenergic receptors",
         "Fatigue, bradycardia,\nbronchospasm, masks hypoglycemia,\nlipid changes",
         "HFrEF, post-MI, angina, AF rate\ncontrol, pregnancy (labetalol).\nAVOID: asthma, severe bradycardia"],
        ["MRA / K-sparing",
         "Spironolactone\nEplerenone",
         "Block aldosterone receptor\n→ Na excretion, K retention",
         "Hyperkalemia, gynecomastia\n(spironolactone), menstrual changes",
         "Resistant HTN (4th-line add-on);\nHFrEF, post-MI with HF;\nprimary hyperaldosteronism"],
        ["Alpha-1 Blockers",
         "Doxazosin\nPrazosin\nPhentolamine (IV)",
         "Block α1 receptors\n→ vasodilation",
         "First-dose orthostatic\nhypotension, reflex tachycardia",
         "HTN + BPH; phaeochromocytoma\n(phentolamine FIRST before β-blocker).\nNot first-line alone"],
        ["Central α2-Agonists",
         "Methyldopa\nClonidine",
         "Stimulate α2 receptors in CNS\n→ reduce sympathetic outflow",
         "Sedation, dry mouth;\nrebound HTN on withdrawal\n(clonidine)",
         "Methyldopa: drug of choice in\npregnancy. Clonidine: resistant HTN.\nNot 1st-line otherwise"],
    ]

    dc_data = [dc_header] + [[p(r[0], cell_bold)] + [p(x, cell_body) for x in r[1:]] for r in dc_rows]
    row_colors_dc = [LTBLUE, LTTEAL, LTBLUE, LTTEAL, LTBLUE, LTTEAL,
                     LTBLUE, LTTEAL, LTBLUE, LTTEAL]

    dc_tbl = Table(dc_data, colWidths=dc_col_w_pts, repeatRows=1)
    dc_style = [
        ("BACKGROUND",   (0,0), (-1,0), colors.HexColor("#1e5e3e")),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,0), 8),
        ("ALIGN",        (0,0), (-1,0), "CENTER"),
        ("VALIGN",       (0,0), (-1,-1),"MIDDLE"),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 4),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("GRID",         (0,0), (-1,-1), 0.4, GREY2),
        ("FONTNAME",     (0,1), (0,-1), "Helvetica-Bold"),
    ]
    for i, bg in enumerate(row_colors_dc, start=1):
        dc_style.append(("BACKGROUND", (0,i), (-1,i), bg))
    dc_tbl.setStyle(TableStyle(dc_style))
    elems.append(dc_tbl)
    elems.append(Spacer(1, 4*mm))

    return elems

# ─────────────────────────────────────────────────────────────────────────────
# PAGE 2  –  Special Situations + Hypertensive Emergency + Avoid table
# ─────────────────────────────────────────────────────────────────────────────

def build_page2():
    elems = []
    elems.append(PageBreak())

    # Header (repeat)
    header_data = [[p("BP MEDICATIONS  |  QUICK REFERENCE CHART  (Page 2)", title_style)]]
    header_tbl = Table(header_data, colWidths=[267*mm])
    header_tbl.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), NAVY),
        ("TOPPADDING",  (0,0), (-1,-1), 8),
        ("BOTTOMPADDING",(0,0),(-1,-1), 6),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 6),
    ]))
    elems.append(header_tbl)
    elems.append(Spacer(1, 4*mm))

    # ── Algorithm box ─────────────────────────────────────────────────────
    algo_hdr = Table([[p("STEP-UP TREATMENT ALGORITHM  (Uncomplicated HTN)", section_style)]],
                     colWidths=[267*mm])
    algo_hdr.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), AMBER),
        ("TOPPADDING",  (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 4),
    ]))
    elems.append(algo_hdr)
    elems.append(Spacer(1, 2*mm))

    algo_col_w = [25, 55, 110, 77]
    algo_data = [
        [p("Step", cell_center_bold), p("Regimen", cell_center_bold),
         p("Detail", cell_center_bold), p("When to use", cell_center_bold)],
        [p("1", cell_center_bold),
         p("Dual combination", cell_bold),
         p("ACEi or ARB  +  CCB  or  Thiazide diuretic", cell_body),
         p("All patients BP ≥140/90 mmHg\n(monotherapy if BP just >140/90 or very elderly)", cell_body)],
        [p("2", cell_center_bold),
         p("Triple combination", cell_bold),
         p("ACEi or ARB  +  CCB  +  Thiazide diuretic", cell_body),
         p("Dual combo insufficient to reach target", cell_body)],
        [p("3", cell_center_bold),
         p("Resistant HTN", cell_bold),
         p("Triple combo  +  Spironolactone 25-50 mg OD\n(or alpha-blocker or beta-blocker)", cell_body),
         p("BP still uncontrolled on 3 drugs;\nrefer to specialist", cell_body)],
        [p("★", cell_center_bold),
         p("Beta-blockers", cell_bold),
         p("Add at ANY step if specific indication present", cell_body),
         p("HFrEF, angina, AF, post-MI,\npregnancy (labetalol)", cell_body)],
    ]
    algo_tbl = Table(algo_data, colWidths=[x*mm for x in algo_col_w], repeatRows=1)
    algo_tbl.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,0), colors.HexColor("#9b5e04")),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,0), 8),
        ("ALIGN",        (0,0), (-1,0), "CENTER"),
        ("VALIGN",       (0,0), (-1,-1),"MIDDLE"),
        ("TOPPADDING",   (0,0), (-1,-1), 4),
        ("BOTTOMPADDING",(0,0), (-1,-1), 4),
        ("LEFTPADDING",  (0,0), (-1,-1), 5),
        ("RIGHTPADDING", (0,0), (-1,-1), 5),
        ("GRID",         (0,0), (-1,-1), 0.4, GREY2),
        ("ROWBACKGROUNDS",(0,1),(-1,-1),[LTAMBER, WHITE, LTAMBER, WHITE]),
        ("FONTNAME",     (0,1), (1,-1), "Helvetica-Bold"),
        ("BACKGROUND",   (0,4), (-1,4), colors.HexColor("#fff0d0")),
    ]))
    elems.append(algo_tbl)
    elems.append(Spacer(1, 4*mm))

    # ── Two-column section: Special Situations | Hypertensive Emergency ──
    # Special situations table
    sp_hdr_data = [[p("SPECIAL CLINICAL SITUATIONS", section_style)]]
    sp_hdr_tbl = Table(sp_hdr_data, colWidths=[130*mm])
    sp_hdr_tbl.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), colors.HexColor("#5b2d8e")),
        ("TOPPADDING",  (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 4),
    ]))

    sp_rows = [
        [p("Situation", cell_center_bold), p("Preferred Drug(s)", cell_center_bold)],
        [p("Pregnancy", cell_bold), p("Methyldopa  |  Labetalol  |  Nifedipine SR", cell_body)],
        [p("Elderly / Isolated systolic HTN", cell_bold), p("Amlodipine  |  Chlorthalidone", cell_body)],
        [p("Black / African-descent patients", cell_bold), p("CCB or Thiazide (RAS blockers less\neffective as monotherapy)", cell_body)],
        [p("CKD + Proteinuria", cell_bold), p("ACEi or ARB (renoprotective)", cell_body)],
        [p("Metabolic syndrome / Pre-diabetes", cell_bold), p("ACEi or ARB or CCB\n(avoid thiazide+BB combo)", cell_body)],
        [p("Post-renal transplant", cell_bold), p("CCB (amlodipine) — first-line", cell_body)],
        [p("Bilateral renal artery stenosis", cell_bold), p("CCB or diuretic\n(AVOID ACEi / ARBs)", cell_body)],
        [p("Aortic aneurysm / Marfan syndrome", cell_bold), p("Beta-blocker (atenolol/metoprolol)\nor ARB (losartan)", cell_body)],
        [p("Migraines", cell_bold), p("Beta-blocker (propranolol, metoprolol)\nor verapamil", cell_body)],
        [p("Raynaud's phenomenon", cell_bold), p("Amlodipine (vasodilatory CCB)\nAVOID non-selective beta-blockers", cell_body)],
        [p("Hyperthyroidism / Thyroid storm", cell_bold), p("Beta-blocker (propranolol)", cell_body)],
    ]
    sp_tbl = Table(sp_rows, colWidths=[50*mm, 78*mm])
    sp_tbl.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,0), colors.HexColor("#5b2d8e")),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,0), 7.5),
        ("ALIGN",        (0,0), (-1,0), "CENTER"),
        ("VALIGN",       (0,0), (-1,-1),"MIDDLE"),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 4),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("GRID",         (0,0), (-1,-1), 0.4, GREY2),
        ("ROWBACKGROUNDS",(0,1),(-1,-1),[colors.HexColor("#f3eeff"), WHITE]),
        ("FONTNAME",     (0,1), (0,-1), "Helvetica-Bold"),
    ]))

    # Hypertensive emergency table
    em_hdr_data = [[p("HYPERTENSIVE EMERGENCY  –  IV Agents", section_style)]]
    em_hdr_tbl = Table(em_hdr_data, colWidths=[131*mm])
    em_hdr_tbl.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), RED),
        ("TOPPADDING",  (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 4),
    ]))

    em_rows = [
        [p("Emergency Type", cell_center_bold), p("Preferred Agent(s)", cell_center_bold), p("Avoid", cell_center_bold)],
        [p("Hypertensive\nEncephalopathy", cell_bold), p("Nicardipine, Labetalol,\nClevidipine", cell_body),
         p("Nitroprusside", cell_body)],
        [p("Acute Ischemic\nStroke", cell_bold), p("Nicardipine, Labetalol,\nClevidipine", cell_body),
         p("Nitroprusside, Nimodipine", cell_body)],
        [p("Haemorrhagic\nStroke", cell_bold), p("Nicardipine, Labetalol", cell_body),
         p("Nitroprusside", cell_body)],
        [p("Aortic Dissection", cell_bold), p("Esmolol (IV) + Nitroprusside\nor Labetalol", cell_body),
         p("Hydralazine\n(reflex tachycardia)", cell_body)],
        [p("Acute Pulmonary\nOedema", cell_bold), p("IV Nitroglycerine +\nFurosemide + Nicardipine", cell_body),
         p("Beta-blockers", cell_body)],
        [p("Acute MI + HTN", cell_bold), p("Beta-blocker +\nNitroglycerine + ACEi", cell_body),
         p("Hydralazine", cell_body)],
        [p("Eclampsia /\nSevere pre-eclampsia", cell_bold), p("IV Hydralazine, IV Labetalol,\nIV MgSO4 (seizures)", cell_body),
         p("ACEi, ARBs", cell_body)],
        [p("Phaeochromocytoma\nCrisis", cell_bold), p("Phentolamine (alpha-blocker)\nTHEN beta-blocker", cell_body),
         p("Beta-blocker FIRST\n(paradoxical HTN!)", cell_body)],
        [p("Renal Crisis\n(Scleroderma)", cell_bold), p("ACE Inhibitor\n(captopril)", cell_body),
         p("ARB (less evidence)", cell_body)],
    ]
    em_tbl = Table(em_rows, colWidths=[38*mm, 54*mm, 39*mm])
    em_tbl.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,0), RED),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,0), 7.5),
        ("ALIGN",        (0,0), (-1,0), "CENTER"),
        ("VALIGN",       (0,0), (-1,-1),"MIDDLE"),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 4),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("GRID",         (0,0), (-1,-1), 0.4, GREY2),
        ("ROWBACKGROUNDS",(0,1),(-1,-1),[LTRED, WHITE]),
        ("FONTNAME",     (0,1), (0,-1), "Helvetica-Bold"),
    ]))

    # Side-by-side layout
    two_col_header = Table(
        [[sp_hdr_tbl, Spacer(6*mm, 1), em_hdr_tbl]],
        colWidths=[130*mm, 6*mm, 131*mm]
    )
    two_col_header.setStyle(TableStyle([
        ("VALIGN", (0,0), (-1,-1), "TOP"),
        ("TOPPADDING", (0,0), (-1,-1), 0),
        ("BOTTOMPADDING", (0,0), (-1,-1), 0),
        ("LEFTPADDING", (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ]))
    elems.append(two_col_header)
    elems.append(Spacer(1, 2*mm))

    two_col = Table(
        [[sp_tbl, Spacer(6*mm, 1), em_tbl]],
        colWidths=[130*mm, 6*mm, 131*mm]
    )
    two_col.setStyle(TableStyle([
        ("VALIGN", (0,0), (-1,-1), "TOP"),
        ("TOPPADDING", (0,0), (-1,-1), 0),
        ("BOTTOMPADDING", (0,0), (-1,-1), 0),
        ("LEFTPADDING", (0,0), (-1,-1), 0),
        ("RIGHTPADDING", (0,0), (-1,-1), 0),
    ]))
    elems.append(two_col)
    elems.append(Spacer(1, 4*mm))

    # ── AVOID table ───────────────────────────────────────────────────────
    av_hdr = Table([[p("DRUGS TO AVOID IN SPECIFIC CONDITIONS", section_style)]],
                   colWidths=[267*mm])
    av_hdr.setStyle(TableStyle([
        ("BACKGROUND",  (0,0), (-1,-1), RED),
        ("TOPPADDING",  (0,0), (-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
        ("ROUNDEDCORNERS",(0,0),(-1,-1), 4),
    ]))
    elems.append(av_hdr)
    elems.append(Spacer(1, 2*mm))

    av_col_w = [65, 202]
    av_rows = [
        [p("Condition", cell_center_bold), p("Drug(s) to Avoid  (with reason)", cell_center_bold)],
        [p("Pregnancy", cell_bold), p("ACEi, ARBs, Direct Renin Inhibitors (aliskiren)  –  all TERATOGENIC", cell_body)],
        [p("Bilateral renal artery stenosis", cell_bold), p("ACEi / ARBs  –  can precipitate acute renal failure", cell_body)],
        [p("Hyperkalaemia", cell_bold), p("ACEi, ARBs, MRA (spironolactone), K-sparing diuretics  –  worsen hyperkalaemia", cell_body)],
        [p("Asthma / COPD", cell_bold), p("Non-selective beta-blockers (propranolol)  –  bronchospasm; use cardioselective (bisoprolol) with caution only if essential", cell_body)],
        [p("AV block (2nd / 3rd degree)", cell_bold), p("Verapamil, Diltiazem, Beta-blockers  –  worsen AV conduction block; risk of asystole", cell_body)],
        [p("Gout", cell_bold), p("Thiazide diuretics  –  raise serum uric acid; worsen gout attacks", cell_body)],
        [p("Decompensated / acute HF", cell_bold), p("Verapamil, Non-DHP CCBs  –  negative inotropy worsens acute failure", cell_body)],
        [p("Phaeochromocytoma", cell_bold), p("Beta-blockers FIRST without alpha-blockade  –  causes paradoxical severe HTN (unopposed alpha stimulation)", cell_body)],
        [p("Metabolic syndrome / Diabetes risk", cell_bold), p("Thiazide + Beta-blocker combination  –  synergistically worsen insulin resistance and glucose tolerance", cell_body)],
    ]
    av_tbl = Table(av_rows, colWidths=[x*mm for x in av_col_w])
    av_tbl.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,0), RED),
        ("TEXTCOLOR",    (0,0), (-1,0), WHITE),
        ("FONTNAME",     (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,0), 8),
        ("ALIGN",        (0,0), (-1,0), "CENTER"),
        ("VALIGN",       (0,0), (-1,-1),"MIDDLE"),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 5),
        ("RIGHTPADDING", (0,0), (-1,-1), 5),
        ("GRID",         (0,0), (-1,-1), 0.4, GREY2),
        ("ROWBACKGROUNDS",(0,1),(-1,-1),[LTRED, WHITE]),
        ("FONTNAME",     (0,1), (0,-1), "Helvetica-Bold"),
    ]))
    elems.append(av_tbl)
    elems.append(Spacer(1, 4*mm))

    # ── Footer note ───────────────────────────────────────────────────────
    elems.append(HRFlowable(width="100%", thickness=0.5, color=GREY2))
    elems.append(Spacer(1, 2*mm))
    elems.append(p(
        "Sources: JNC 7 Guidelines | ACC/AHA 2018 | Comprehensive Clinical Nephrology 7e | "
        "NKF Primer 8e | Textbook of Family Medicine 9e | Goldman-Cecil Medicine | Lippincott Pharmacology  |  "
        "For clinical decisions, always verify against current local guidelines.",
        small_note
    ))
    return elems

# ── BUILD PDF ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=landscape(A4),
    leftMargin=12*mm, rightMargin=12*mm,
    topMargin=10*mm, bottomMargin=10*mm
)
story = build_page1() + build_page2()
doc.build(story)
print(f"PDF created: {OUTPUT}")

<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>BP Medications Quick Reference</title>
<style>
  * { box-sizing: border-box; margin: 0; padding: 0; }
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  td { padding: 6px 8px; vertical-align: middle; border: 1px solid #dce0e5; }
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  /* Compelling indications */
  #ci th { background: #1a3a5c; color: white; border: 1px solid #2a5c8a; }
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  #ci td { text-align: center; }
  #ci td:first-child { text-align: left; }
  .tick { color: #1e7d44; font-size: 15px; font-weight: bold; }
  .dash { color: #aaa; }

  /* Drug class table */
  #dc th { background: #1e5e3e; color: white; border: 1px solid #2a8a5e; }
  #dc .td-label { background: #dceef5 !important; }
  #dc tr:nth-child(even) td { background: #d4f0f0; }
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  /* Algorithm */
  #algo th { background: #9b5e04; color: white; border: 1px solid #d4830a; }
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  .algo-star td { background: #fff0d0 !important; }

  /* Two-col layout */
  .two-col { display: flex; gap: 14px; margin-bottom: 14px; }
  .two-col > div { flex: 1; }

  /* Special situations */
  #sp th { background: #5b2d8e; color: white; border: 1px solid #7b4dae; }
  #sp .td-label { background: #f3eeff !important; }
  #sp tr:nth-child(even) td { background: #f3eeff; }
  #sp tr:nth-child(odd) td { background: #ffffff; }

  /* Emergency */
  #em th { background: #c0392b; color: white; border: 1px solid #e05040; }
  #em .td-label { background: #fde8e6 !important; }
  #em tr:nth-child(even) td { background: #fde8e6; }
  #em tr:nth-child(odd) td { background: #ffffff; }

  /* Avoid */
  #av th { background: #c0392b; color: white; border: 1px solid #e05040; }
  #av .td-label { background: #fde8e6 !important; }
  #av tr:nth-child(even) td { background: #fde8e6; }
  #av tr:nth-child(odd) td { background: #ffffff; }

  .page-break { border: none; border-top: 3px dashed #ccc; margin: 20px 0; }

  .footer { text-align: center; font-size: 10px; color: #777; margin-top: 8px; padding: 8px; border-top: 1px solid #dce0e5; }

  .print-btn {
    display: block; margin: 0 auto 16px; padding: 12px 30px;
    background: #1a3a5c; color: white; font-size: 15px; font-weight: bold;
    border: none; border-radius: 8px; cursor: pointer; letter-spacing: 0.5px;
  }
  .print-btn:hover { background: #2a6090; }

  @media print {
    .print-btn { display: none !important; }
    body { background: white; font-size: 10px; }
    .page { padding: 8px; max-width: 100%; }
    .header h1 { font-size: 16px; }
    .two-col { gap: 8px; }
    td, th { padding: 4px 5px; font-size: 9.5px; }
    .section-title { font-size: 11px; padding: 5px 8px; }
    @page { size: A4 landscape; margin: 8mm; }
  }
</style>
</head>
<body>
<div class="page">

  <button class="print-btn" onclick="window.print()">🖨️ Print / Save as PDF</button>

  <!-- HEADER -->
  <div class="header">
    <h1>BP MEDICATIONS — QUICK REFERENCE CHART</h1>
    <p>JNC 7 · ACC/AHA 2018 · Comprehensive Clinical Nephrology 7e · NKF Primer 8e</p>
  </div>

  <!-- SECTION 1: Compelling Indications -->
  <div class="section-title teal">COMPELLING INDICATIONS (JNC 7 / ACC-AHA 2018)</div>
  <table id="ci">
    <thead><tr>
      <th style="text-align:left">Condition</th>
      <th>Diuretic<br>(Thiazide)</th>
      <th>Beta-<br>Blocker</th>
      <th>ACE<br>Inhibitor</th>
      <th>ARB</th>
      <th>CCB</th>
      <th>MRA<br>(Spiro)</th>
      <th>Notes</th>
    </tr></thead>
    <tbody>
      <tr><td class="td-label">Heart Failure (HFrEF)</td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td>Avoid verapamil / diltiazem</td></tr>
      <tr><td class="td-label">Post-MI</td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td>Beta-blocker within 24 h</td></tr>
      <tr><td class="td-label">High CAD Risk / Angina</td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td>CCB: prefer amlodipine</td></tr>
      <tr><td class="td-label">Diabetes Mellitus</td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td>ACEi/ARB renoprotective</td></tr>
      <tr><td class="td-label">CKD / Proteinuria</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>ACEi or ARB first-line</td></tr>
      <tr><td class="td-label">Stroke Prevention (Recurrent)</td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>Thiazide + ACEi combo</td></tr>
      <tr><td class="td-label">Atrial Fibrillation (Rate control)</td><td><span class="dash">—</span></td><td><span class="tick">✔</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>✔ non-DHP<br>(diltiazem)</td><td><span class="dash">—</span></td><td>Avoid DHP CCBs alone</td></tr>
      <tr><td class="td-label">Pregnancy</td><td><span class="dash">—</span></td><td>✔ Labetalol only</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>✔ Nifedipine SR</td><td><span class="dash">—</span></td><td>Methyldopa also safe</td></tr>
      <tr><td class="td-label">BPH</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>Alpha-blocker (doxazosin)</td></tr>
      <tr><td class="td-label">Phaeochromocytoma</td><td><span class="dash">—</span></td><td>✔ After alpha-block</td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td><span class="dash">—</span></td><td>Phentolamine FIRST, then BB</td></tr>
    </tbody>
  </table>

  <!-- SECTION 2: Drug Classes -->
  <div class="section-title green">DRUG CLASS SUMMARY — Mechanisms, Side Effects &amp; Key Indications</div>
  <table id="dc">
    <thead><tr>
      <th style="text-align:left">Drug Class</th>
      <th>Examples</th>
      <th>Mechanism</th>
      <th>Side Effects</th>
      <th style="text-align:left">Key Indications / Notes</th>
    </tr></thead>
    <tbody>
      <tr><td class="td-label">Thiazide / Thiazide-like Diuretics</td><td>HCTZ, Chlorthalidone, Indapamide</td><td>Inhibit Na-Cl cotransporter (DCT)</td><td>Hypokalemia, hyperuricemia, hyperglycemia, dyslipidemia</td><td>First-line uncomplicated HTN; HF; CAD; stroke. Chlorthalidone preferred over HCTZ.</td></tr>
      <tr><td class="td-label">Loop Diuretics</td><td>Furosemide, Bumetanide</td><td>Inhibit Na-K-2Cl cotransporter (thick ascending limb)</td><td>Hypokalemia, ototoxicity, dehydration</td><td>HTN + volume overload; HF; CKD with GFR &lt;30 (thiazides lose efficacy)</td></tr>
      <tr><td class="td-label">ACE Inhibitors</td><td>Ramipril, Lisinopril, Enalapril, Perindopril</td><td>Block Ang I → Ang II conversion; bradykinin accumulation</td><td>Dry cough (10-15%), hyperkalemia, ↑creatinine, angioedema (rare)</td><td>HF, post-MI, CKD with proteinuria, diabetes, stroke. AVOID: pregnancy, bilateral RAS.</td></tr>
      <tr><td class="td-label">ARBs (Angiotensin Receptor Blockers)</td><td>Losartan, Valsartan, Telmisartan, Irbesartan</td><td>Block Ang II at AT1 receptor (no bradykinin)</td><td>Similar to ACEi — NO cough; rare angioedema</td><td>Same as ACEi. Preferred when ACEi cough intolerable. AVOID: pregnancy, bilateral RAS.</td></tr>
      <tr><td class="td-label">Dihydropyridine CCBs (DHP)</td><td>Amlodipine, Nifedipine SR, Felodipine</td><td>Block L-type Ca²⁺ channels → vasodilation</td><td>Peripheral edema, flushing, gingival hyperplasia</td><td>Uncomplicated HTN, elderly, isolated systolic HTN, angina, CKD, black patients, diabetes</td></tr>
      <tr><td class="td-label">Non-DHP CCBs</td><td>Diltiazem, Verapamil</td><td>Block L-type Ca²⁺ channels + AV nodal depression</td><td>Bradycardia, AV block; verapamil: constipation</td><td>HTN + angina + AF rate control. AVOID: HFrEF, AV block, combined with beta-blockers.</td></tr>
      <tr><td class="td-label">Beta-Blockers</td><td>Metoprolol, Atenolol, Carvedilol, Bisoprolol, Labetalol (IV/oral)</td><td>Block β1 (and β2 if non-selective) adrenergic receptors</td><td>Fatigue, bradycardia, bronchospasm, masks hypoglycemia</td><td>HFrEF, post-MI, angina, AF rate control, pregnancy (labetalol). AVOID: asthma, severe bradycardia.</td></tr>
      <tr><td class="td-label">MRA / K-sparing (Spironolactone)</td><td>Spironolactone, Eplerenone</td><td>Block aldosterone receptor → Na excretion, K retention</td><td>Hyperkalemia, gynecomastia (spironolactone), menstrual changes</td><td>Resistant HTN (4th-line add-on); HFrEF; post-MI with HF; primary hyperaldosteronism</td></tr>
      <tr><td class="td-label">Alpha-1 Blockers</td><td>Doxazosin, Prazosin, Phentolamine (IV)</td><td>Block α1 receptors → vasodilation</td><td>First-dose orthostatic hypotension, reflex tachycardia</td><td>HTN + BPH; phaeochromocytoma (phentolamine FIRST before β-blocker). Not first-line alone.</td></tr>
      <tr><td class="td-label">Central α2-Agonists</td><td>Methyldopa, Clonidine</td><td>Stimulate α2 in CNS → reduce sympathetic outflow</td><td>Sedation, dry mouth; rebound HTN on withdrawal (clonidine)</td><td>Methyldopa: drug of choice in pregnancy. Clonidine: resistant HTN. Not 1st-line otherwise.</td></tr>
    </tbody>
  </table>

  <hr class="page-break">

  <!-- SECTION 3: Algorithm -->
  <div class="section-title amber">STEP-UP TREATMENT ALGORITHM (Uncomplicated HTN)</div>
  <table id="algo">
    <thead><tr>
      <th>Step</th><th>Regimen</th><th>Detail</th><th>When to Use</th>
    </tr></thead>
    <tbody>
      <tr><td style="text-align:center;font-weight:bold">1</td><td class="td-label">Dual combination</td><td><strong>ACEi or ARB + CCB</strong> or <strong>Thiazide diuretic</strong></td><td>All patients BP ≥140/90 mmHg (monotherapy if BP just &gt;140/90 or very elderly/frail)</td></tr>
      <tr><td style="text-align:center;font-weight:bold">2</td><td class="td-label">Triple combination</td><td><strong>ACEi or ARB + CCB + Thiazide diuretic</strong></td><td>Dual combo insufficient to reach BP target</td></tr>
      <tr><td style="text-align:center;font-weight:bold">3</td><td class="td-label">Resistant HTN</td><td>Triple combo + <strong>Spironolactone 25–50 mg OD</strong> (or alpha-blocker or beta-blocker)</td><td>BP uncontrolled on 3 drugs; refer to specialist</td></tr>
      <tr class="algo-star"><td style="text-align:center;font-weight:bold">★</td><td class="td-label">Beta-blockers</td><td>Add at <strong>ANY step</strong> when specific indication present</td><td>HFrEF, angina, AF, post-MI, pregnancy (labetalol)</td></tr>
    </tbody>
  </table>

  <!-- SECTION 4: Two-col -->
  <div class="two-col">
    <div>
      <div class="section-title purple">SPECIAL CLINICAL SITUATIONS</div>
      <table id="sp">
        <thead><tr><th style="text-align:left">Situation</th><th style="text-align:left">Preferred Drug(s)</th></tr></thead>
        <tbody>
          <tr><td class="td-label">Pregnancy</td><td>Methyldopa | Labetalol | Nifedipine SR</td></tr>
          <tr><td class="td-label">Elderly / Isolated systolic HTN</td><td>Amlodipine | Chlorthalidone</td></tr>
          <tr><td class="td-label">Black / African-descent patients</td><td>CCB or Thiazide (RAS blockers less effective as monotherapy)</td></tr>
          <tr><td class="td-label">CKD + Proteinuria</td><td>ACEi or ARB (renoprotective)</td></tr>
          <tr><td class="td-label">Metabolic syndrome / Pre-diabetes</td><td>ACEi or ARB or CCB (avoid thiazide+BB combo)</td></tr>
          <tr><td class="td-label">Post-renal transplant</td><td>CCB (amlodipine) — first-line</td></tr>
          <tr><td class="td-label">Bilateral renal artery stenosis</td><td>CCB or diuretic (AVOID ACEi / ARBs)</td></tr>
          <tr><td class="td-label">Aortic aneurysm / Marfan</td><td>Beta-blocker (atenolol) or ARB (losartan)</td></tr>
          <tr><td class="td-label">Migraines</td><td>Beta-blocker (propranolol, metoprolol) or verapamil</td></tr>
          <tr><td class="td-label">Raynaud's phenomenon</td><td>Amlodipine. AVOID non-selective beta-blockers.</td></tr>
          <tr><td class="td-label">Hyperthyroidism / Thyroid storm</td><td>Beta-blocker (propranolol)</td></tr>
        </tbody>
      </table>
    </div>
    <div>
      <div class="section-title red">HYPERTENSIVE EMERGENCY — IV Agents</div>
      <table id="em">
        <thead><tr><th style="text-align:left">Emergency Type</th><th>Preferred Agent(s)</th><th>Avoid</th></tr></thead>
        <tbody>
          <tr><td class="td-label">HTN Encephalopathy</td><td>Nicardipine, Labetalol, Clevidipine</td><td>Nitroprusside</td></tr>
          <tr><td class="td-label">Acute Ischaemic Stroke</td><td>Nicardipine, Labetalol, Clevidipine</td><td>Nitroprusside, Nimodipine</td></tr>
          <tr><td class="td-label">Haemorrhagic Stroke</td><td>Nicardipine, Labetalol</td><td>Nitroprusside</td></tr>
          <tr><td class="td-label">Aortic Dissection</td><td>Esmolol IV + Nitroprusside or Labetalol</td><td>Hydralazine (reflex tachycardia)</td></tr>
          <tr><td class="td-label">Acute Pulmonary Oedema</td><td>IV Nitroglycerine + Furosemide + Nicardipine</td><td>Beta-blockers</td></tr>
          <tr><td class="td-label">Acute MI + HTN</td><td>Beta-blocker + Nitroglycerine + ACEi</td><td>Hydralazine</td></tr>
          <tr><td class="td-label">Eclampsia / Severe Pre-eclampsia</td><td>IV Hydralazine, IV Labetalol, IV MgSO4 (seizures)</td><td>ACEi, ARBs</td></tr>
          <tr><td class="td-label">Phaeochromocytoma Crisis</td><td>Phentolamine (alpha-blocker) THEN beta-blocker</td><td>Beta-blocker FIRST (paradoxical HTN!)</td></tr>
          <tr><td class="td-label">Scleroderma Renal Crisis</td><td>ACE Inhibitor (captopril)</td><td>ARB (less evidence)</td></tr>
        </tbody>
      </table>
      <p style="font-size:10.5px;color:#c0392b;font-weight:bold;margin-top:4px;">⚠ Reduce BP by max 25% in first hour. Never drop too fast — risk of ischaemia.</p>
    </div>
  </div>

  <!-- SECTION 5: Avoid -->
  <div class="section-title red">DRUGS TO AVOID IN SPECIFIC CONDITIONS</div>
  <table id="av">
    <thead><tr>
      <th style="text-align:left">Condition</th>
      <th style="text-align:left">Drug(s) to Avoid &amp; Reason</th>
    </tr></thead>
    <tbody>
      <tr><td class="td-label">Pregnancy</td><td>ACEi, ARBs, Direct Renin Inhibitors (aliskiren) — all TERATOGENIC</td></tr>
      <tr><td class="td-label">Bilateral renal artery stenosis</td><td>ACEi / ARBs — can precipitate acute renal failure</td></tr>
      <tr><td class="td-label">Hyperkalaemia</td><td>ACEi, ARBs, MRA (spironolactone), K-sparing diuretics — worsen hyperkalaemia</td></tr>
      <tr><td class="td-label">Asthma / COPD</td><td>Non-selective beta-blockers (propranolol) — bronchospasm. Use cardioselective (bisoprolol) with caution if essential.</td></tr>
      <tr><td class="td-label">AV block (2nd / 3rd degree)</td><td>Verapamil, Diltiazem, Beta-blockers — worsen conduction block; risk of asystole</td></tr>
      <tr><td class="td-label">Gout</td><td>Thiazide diuretics — raise serum uric acid; worsen gout attacks</td></tr>
      <tr><td class="td-label">Decompensated / acute HF</td><td>Verapamil, Non-DHP CCBs — negative inotropy worsens acute failure</td></tr>
      <tr><td class="td-label">Phaeochromocytoma</td><td>Beta-blockers FIRST (without alpha-blockade) — paradoxical severe HTN from unopposed alpha stimulation</td></tr>
      <tr><td class="td-label">Metabolic syndrome / Diabetes risk</td><td>Thiazide + Beta-blocker combination — synergistically worsen insulin resistance and glucose tolerance</td></tr>
    </tbody>
  </table>

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    Sources: JNC 7 Guidelines · ACC/AHA 2018 · Comprehensive Clinical Nephrology 7e · NKF Primer 8e · Textbook of Family Medicine 9e · Goldman-Cecil Medicine · Lippincott Pharmacology<br>
    For clinical decisions, always verify against current local guidelines.
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