Cookbook 369: Offline Clinical Emergency Cardiology Acute Aortic Dissection Stanford/DeBakey Staging, ADD-RS & Anti-Impulse Titrator Engine

"""
Offline Clinical Emergency Cardiology Acute Aortic Dissection Stanford/DeBakey Staging,
ADD-RS & Anti-Impulse Titrator Engine.
Zero external cloud API reliance. Pure offline Python.
"""

import sys
from dataclasses import dataclass, field
from enum import Enum
from typing import List, Optional

# Enforce UTF-8 standard output for Windows CLI environments
if hasattr(sys.stdout, "reconfigure"):
    sys.stdout.reconfigure(encoding="utf-8")


class StanfordClassification(str, Enum):
    TYPE_A = "Stanford Type A (Involves Ascending Aorta - Emergent Open Surgical Repair)"
    TYPE_B = "Stanford Type B (Confined to Descending Aorta Distal to Left Subclavian Artery)"
    NONE_OR_INDETERMINATE = "Indeterminate / Rule-Out Required"


class DeBakeyClassification(str, Enum):
    TYPE_I = "DeBakey Type I (Originates in ascending aorta, extends distally through arch to descending aorta)"
    TYPE_II = "DeBakey Type II (Confined strictly to ascending aorta)"
    TYPE_III_A = "DeBakey Type IIIa (Originates in descending aorta, confined to thoracic aorta above diaphragm)"
    TYPE_III_B = "DeBakey Type IIIb (Originates in descending aorta, extends below diaphragm into abdominal aorta/iliac)"
    NOT_APPLICABLE = "Not Applicable / Aortic Dissection Excluded"


class MalperfusionOrgan(str, Enum):
    CORONARY = "Coronary Arterial Malperfusion (Acute Inferior/Anterior STEMI)"
    CEREBROVASCULAR = "Cerebrovascular / Arch Branch Malperfusion (Acute Stroke / TIA / Altered Mental Status)"
    SPINAL_CORD = "Spinal Cord Ischemia (Anterior Spinal Artery Syndrome / Acute Paraplegia)"
    MESENTERIC = "Mesenteric / Visceral Ischemia (Severe Abdominal Pain, Acute Metabolic Acidemia, Bowel Infarction)"
    RENAL = "Renal Artery Malperfusion (Acute Oliguria, Doubling of Creatinine, Refractory Renovascular HTN)"
    LOWER_EXTREMITY = "Acute Lower Extremity Limb Ischemia (Absent Femoral/Distal Pulses, Pallor, Poikilothermia, Paralysis)"


@dataclass
class AorticPatientProfile:
    patient_id: str
    age_years: int
    # High-Risk Predisposing Conditions (ADD-RS Category 1)
    has_marfan_or_connective_tissue_disorder: bool = False
    has_known_aortic_aneurysm: bool = False
    has_prior_aortic_valve_disease_or_manipulation: bool = False
    has_bicuspid_aortic_valve: bool = False
    # High-Risk Pain Features (ADD-RS Category 2)
    has_abrupt_onset_pain: bool = False
    has_severe_intensity_pain: bool = False
    has_ripping_tearing_sharp_migrating_pain: bool = False
    # High-Risk Examination Features (ADD-RS Category 3)
    has_pulse_deficit_or_blood_pressure_differential_gt20: bool = False
    has_focal_neurological_deficit_with_pain: bool = False
    has_new_murmur_of_aortic_regurgitation: bool = False
    has_hypotension_or_shock: bool = False
    # Lab & Imaging
    d_dimer_ng_ml: Optional[float] = None
    cta_performed: bool = False
    cta_ascending_aorta_involved: bool = False
    cta_descending_aorta_involved: bool = False
    cta_intimal_flap_origin_ascending: bool = False
    cta_intimal_flap_origin_descending: bool = False
    cta_dissection_extends_below_diaphragm: bool = False
    cta_max_aortic_diameter_mm: Optional[float] = None
    cta_periaortic_hematoma_or_rupture: bool = False
    has_pericardial_tamponade: bool = False
    # Malperfusion & Complications
    malperfusion_organs: List[MalperfusionOrgan] = field(default_factory=list)
    has_refractory_pain_or_uncontrolled_hypertension: bool = False
    # Current Vitals
    current_heart_rate_bpm: float = 96.0
    current_systolic_bp_mmhg: float = 178.0
    current_diastolic_bp_mmhg: float = 102.0
    contraindication_to_beta_blockers: bool = False


@dataclass
class AorticDissectionAssessment:
    patient_id: str
    add_rs_score: int
    add_rs_risk_tier: str
    d_dimer_interpretation: str
    imaging_recommendation: str
    stanford_classification: StanfordClassification
    debakey_classification: DeBakeyClassification
    is_complicated_type_b: bool
    anti_impulse_target_hr_bpm: str
    anti_impulse_target_sbp_mmhg: str
    anti_impulse_pharmacotherapy_steps: List[str]
    surgical_triage_urgency: str
    surgical_procedure_recommendation: str
    safety_sentinels: List[str]
    clinical_guideline_directive: str


class AorticDissectionEngine:
    def evaluate_case(self, p: AorticPatientProfile) -> AorticDissectionAssessment:
        sentinels: List[str] = []
        anti_impulse_steps: List[str] = []

        # 1. Calculate ADD-RS (Aortic Dissection Detection Risk Score: 0 to 3 points)
        cat1 = any([
            p.has_marfan_or_connective_tissue_disorder,
            p.has_known_aortic_aneurysm,
            p.has_prior_aortic_valve_disease_or_manipulation,
            p.has_bicuspid_aortic_valve
        ])
        cat2 = any([
            p.has_abrupt_onset_pain,
            p.has_severe_intensity_pain,
            p.has_ripping_tearing_sharp_migrating_pain
        ])
        cat3 = any([
            p.has_pulse_deficit_or_blood_pressure_differential_gt20,
            p.has_focal_neurological_deficit_with_pain,
            p.has_new_murmur_of_aortic_regurgitation,
            p.has_hypotension_or_shock
        ])

        add_rs = int(cat1) + int(cat2) + int(cat3)

        if add_rs == 0:
            risk_tier = "ADD-RS Score 0 (Low Clinical Probability)"
        elif add_rs == 1:
            risk_tier = "ADD-RS Score 1 (Intermediate Clinical Probability)"
        else:
            risk_tier = f"ADD-RS Score {add_rs} (High Clinical Probability - Immediate CTA Indicated)"

        # 2. D-Dimer & ADvISED Trial Rule-Out Integration
        if p.d_dimer_ng_ml is not None:
            if p.d_dimer_ng_ml < 500.0:
                if add_rs == 0:
                    d_dimer_interp = f"D-Dimer {p.d_dimer_ng_ml:.0f} ng/mL (< 500 ng/mL) with ADD-RS 0: Negative Predictive Value > 99.7% (ADvISED Protocol). Acute Aortic Syndrome ruled out; evaluate alternative diagnoses."
                    img_rec = "Definitive CTA Aorta not routinely required if low clinical pre-test probability remains unchanged."
                else:
                    d_dimer_interp = f"D-Dimer {p.d_dimer_ng_ml:.0f} ng/mL (< 500 ng/mL) with ADD-RS >= 1: Negative D-Dimer does NOT safely exclude AAS when clinical risk factors or high-risk pain/exam features are present."
                    img_rec = "Proceed immediately to ECG-gated CTA Aorta (Chest, Abdomen, and Pelvis)."
            else:
                d_dimer_interp = f"D-Dimer {p.d_dimer_ng_ml:.0f} ng/mL (>= 500 ng/mL - Elevated): Markedly elevated D-Dimer mandates urgent definitive aortic imaging."
                img_rec = "Emergency ECG-gated CTA Aorta (Chest, Abdomen, and Pelvis) or bedside TEE if hemodynamically unstable."
        else:
            d_dimer_interp = "D-Dimer not measured."
            img_rec = "Obtain emergent ECG-gated CTA Aorta if clinical suspicion of acute aortic syndrome exists."

        # 3. Anatomic Staging (Stanford & DeBakey)
        stanford = StanfordClassification.NONE_OR_INDETERMINATE
        debakey = DeBakeyClassification.NOT_APPLICABLE
        is_complicated_b = False

        if p.cta_performed:
            if p.cta_ascending_aorta_involved:
                stanford = StanfordClassification.TYPE_A
                if p.cta_descending_aorta_involved:
                    debakey = DeBakeyClassification.TYPE_I
                else:
                    debakey = DeBakeyClassification.TYPE_II
            elif p.cta_descending_aorta_involved:
                stanford = StanfordClassification.TYPE_B
                if p.cta_dissection_extends_below_diaphragm:
                    debakey = DeBakeyClassification.TYPE_III_B
                else:
                    debakey = DeBakeyClassification.TYPE_III_A

        # 4. Complicated Type B Criteria Assessment
        if stanford == StanfordClassification.TYPE_B:
            if (
                len(p.malperfusion_organs) > 0
                or p.cta_periaortic_hematoma_or_rupture
                or p.has_refractory_pain_or_uncontrolled_hypertension
                or (p.cta_max_aortic_diameter_mm is not None and p.cta_max_aortic_diameter_mm >= 55.0)
            ):
                is_complicated_b = True

        # 5. Anti-Impulse Pharmacotherapy Protocol & Gating
        target_hr = "Heart Rate: 55 - 60 bpm (Strict Chronotropic & Inotropic Suppression)"
        target_sbp = "Systolic Blood Pressure: 100 - 120 mmHg (Target MAP 65 - 75 mmHg without malperfusion)"

        if p.has_hypotension_or_shock or p.has_pericardial_tamponade:
            anti_impulse_steps.append("⚠️ HYPOTENSION / TAMPONADE PRESENT: DO NOT administer beta-blockers or vasodilators.")
            anti_impulse_steps.append("Resuscitate with controlled crystalloid / blood products to maintain cerebral/coronary perfusion without precipitating free aortic rupture.")
            sentinels.append("HYPOTENSION / CARDIAC TAMPONADE SENTINEL: Pericardiocentesis in Type A dissection with hemopericardium carries high risk of catastrophic re-bleeding/death; perform controlled small-volume relief ONLY for PEA arrest while entering operating room.")
        else:
            # Step 1: Beta-blocker
            if not p.contraindication_to_beta_blockers:
                anti_impulse_steps.append(
                    "STEP 1 (FIRST-LINE): IV Beta-Blockade: Initiate Esmolol infusion (Loading dose 500 mcg/kg over 1 min, continuous infusion 50-300 mcg/kg/min) OR Labetalol (10-20 mg IV boluses q10m up to 300 mg, then 2-8 mg/min infusion) to suppress dP/dt."
                )
            else:
                anti_impulse_steps.append(
                    "STEP 1 (ALTERNATIVE FOR BETA-BLOCKER CONTRAINDICATION): IV Non-Dihydropyridine Calcium Channel Blocker: Initiate IV Diltiazem (0.25 mg/kg IV over 2 min, then 5-15 mg/h infusion) or Verapamil."
                )

            # Step 2: Vasodilator Adjunct Gating
            if p.current_heart_rate_bpm > 60.0:
                anti_impulse_steps.append(
                    f"⚠️ CURRENT HR {p.current_heart_rate_bpm:.0f} BPM: Titrate beta-blocker to achieve HR <= 60 bpm BEFORE adding pure vasodilators to prevent reflex tachycardia and surge in aortic wall shear stress (dP/dt)."
                )
            else:
                anti_impulse_steps.append(
                    "STEP 2 (SECONDARY VASODILATOR ADJUNCT): Target HR achieved (<= 60 bpm). If SBP remains > 120 mmHg, initiate IV Nicardipine (5-15 mg/h) or Clevidipine (1-2 mg/h) to reach target SBP 100-120 mmHg."
                )

        # 6. Safety Sentinels & Pharmacotherapy Prohibitions
        sentinels.append(
            "HYDRALAZINE PROHIBITION GUARDRAIL: Direct arterial vasodilators (Hydralazine) are ABSOLUTELY CONTRAINDICATED in acute aortic syndromes due to reflex sympathetic activation, increased inotropy, and fatal escalation of aortic shear stress (dP/dt)."
        )
        sentinels.append(
            "PREMATURE VASODILATOR GUARDRAIL: Never start Sodium Nitroprusside, Nicardipine, or Nitroglycerin as monotherapy without prior adequate beta-blockade, as reflex chronotropic surge accelerates intimal flap tearing."
        )

        if p.has_new_murmur_of_aortic_regurgitation and stanford == StanfordClassification.TYPE_A:
            sentinels.append(
                "AORTIC REGURGITATION HEMODYNAMIC SENTINEL: Acute severe aortic regurgitation increases LV end-diastolic pressure; avoid excessive bradycardia (keep HR 60-70 bpm) and avoid intra-aortic balloon pump (IABP is ABSOLUTELY CONTRAINDICATED in aortic dissection / AR)."
            )

        # 7. Surgical Triage Directives
        if stanford == StanfordClassification.TYPE_A:
            surg_urgency = "🚨 LEVEL 1 EMERGENT SURGICAL DISASTER - IMMEDIATE CARDIOTHORACIC OR MOBILIZATION"
            surg_proc = (
                "Immediate Sternotomy, Cardiopulmonary Bypass with Hypothermic Circulatory Arrest, "
                "Ascending Aorta / Hemiarch / Total Arch Replacement with Aortic Valve Resuspension or Root Replacement (Bentall / David Procedure). "
                "Do NOT delay transport for extensive tertiary workup."
            )
        elif stanford == StanfordClassification.TYPE_B:
            if is_complicated_b:
                surg_urgency = "🚨 LEVEL 1 EMERGENT / URGENT ENDOVASCULAR SURGERY - TEVAR GATING"
                surg_proc = (
                    "Thoracic Endovascular Aortic Repair (TEVAR) with vascular surgery / interventional radiology. "
                    "Deploy covered stent-graft across proximal entry tear to seal false lumen, re-expand true lumen, and restore branch vessel perfusion. "
                    "Consider provisional branch stenting / surgical fenestration for persistent malperfusion."
                )
            else:
                surg_urgency = "URGENT ICU ADMISSION - MEDICAL ANTI-IMPULSE REGIMEN & SUBACUTE SURVEILLANCE"
                surg_proc = (
                    "Continuous arterial line hemodynamic monitoring in CTSICU/MICU. Strict oral/IV anti-impulse therapy (HR < 60 bpm, SBP < 120 mmHg). "
                    "Serial CTA imaging at 48-72h, 14 days, and 3 months to detect late aneurysmal degeneration or malperfusion."
                )
        else:
            surg_urgency = "DIAGNOSTIC TRIAGE & MONITORING"
            surg_proc = "Pursue definitive diagnostic imaging; maintain vigilant hemodynamic monitoring."

        directive = (
            f"CLINICAL DIRECTIVE: {risk_tier}. Stanford Classification: {stanford.value}. "
            f"Surgical Urgency: {surg_urgency}. Enforce strict anti-impulse sequence: "
            f"Beta-blocker first to target HR 55-60 bpm, followed by Nicardipine for SBP 100-120 mmHg. "
            f"Strictly prohibit Hydralazine and un-blocked vasodilators."
        )

        return AorticDissectionAssessment(
            patient_id=p.patient_id,
            add_rs_score=add_rs,
            add_rs_risk_tier=risk_tier,
            d_dimer_interpretation=d_dimer_interp,
            imaging_recommendation=img_rec,
            stanford_classification=stanford,
            debakey_classification=debakey,
            is_complicated_type_b=is_complicated_b,
            anti_impulse_target_hr_bpm=target_hr,
            anti_impulse_target_sbp_mmhg=target_sbp,
            anti_impulse_pharmacotherapy_steps=anti_impulse_steps,
            surgical_triage_urgency=surg_urgency,
            surgical_procedure_recommendation=surg_proc,
            safety_sentinels=sentinels,
            clinical_guideline_directive=directive
        )


# =====================================================================
# Verification & Self-Testing Suite
# =====================================================================
if __name__ == "__main__":
    engine = AorticDissectionEngine()

    print("================================================================================")
    print("DEMO 1: Acute Stanford Type A Dissection with Pulse Deficit & Tamponade Warning")
    print("================================================================================")
    case_type_a = AorticPatientProfile(
        patient_id="AAD-TYPEA-901",
        age_years=62,
        has_known_aortic_aneurysm=True,
        has_abrupt_onset_pain=True,
        has_severe_intensity_pain=True,
        has_ripping_tearing_sharp_migrating_pain=True,
        has_pulse_deficit_or_blood_pressure_differential_gt20=True,
        has_new_murmur_of_aortic_regurgitation=True,
        d_dimer_ng_ml=4200.0,
        cta_performed=True,
        cta_ascending_aorta_involved=True,
        cta_descending_aorta_involved=True,
        cta_intimal_flap_origin_ascending=True,
        cta_max_aortic_diameter_mm=58.0,
        cta_periaortic_hematoma_or_rupture=False,
        has_pericardial_tamponade=False,
        current_heart_rate_bpm=94.0,
        current_systolic_bp_mmhg=168.0,
        current_diastolic_bp_mmhg=92.0
    )

    eval_a = engine.evaluate_case(case_type_a)
    print(f"Patient ID: {eval_a.patient_id}")
    print(f"Risk Staging: {eval_a.add_rs_risk_tier}")
    print(f"Stanford: {eval_a.stanford_classification.value}")
    print(f"DeBakey: {eval_a.debakey_classification.value}")
    print(f"Surgical Urgency: {eval_a.surgical_triage_urgency}")
    print(f"Procedure: {eval_a.surgical_procedure_recommendation}")
    print("\nAnti-Impulse Steps:")
    for st in eval_a.anti_impulse_pharmacotherapy_steps:
        print(f"  {st}")
    print("\nSafety Sentinels:")
    for se in eval_a.safety_sentinels:
        print(f"  🚨 {se}")

    print("\n================================================================================")
    print("DEMO 2: Complicated Stanford Type B Dissection with Mesenteric & Renal Malperfusion")
    print("================================================================================")
    case_type_b_comp = AorticPatientProfile(
        patient_id="AAD-TYPEB-902",
        age_years=58,
        has_abrupt_onset_pain=True,
        has_severe_intensity_pain=True,
        has_ripping_tearing_sharp_migrating_pain=True,
        d_dimer_ng_ml=3100.0,
        cta_performed=True,
        cta_ascending_aorta_involved=False,
        cta_descending_aorta_involved=True,
        cta_intimal_flap_origin_descending=True,
        cta_dissection_extends_below_diaphragm=True,
        cta_max_aortic_diameter_mm=48.0,
        malperfusion_organs=[MalperfusionOrgan.MESENTERIC, MalperfusionOrgan.RENAL],
        current_heart_rate_bpm=88.0,
        current_systolic_bp_mmhg=194.0,
        current_diastolic_bp_mmhg=110.0
    )

    eval_b = engine.evaluate_case(case_type_b_comp)
    print(f"Patient ID: {eval_b.patient_id}")
    print(f"Stanford: {eval_b.stanford_classification.value}")
    print(f"DeBakey: {eval_b.debakey_classification.value}")
    print(f"Complicated Type B: {eval_b.is_complicated_type_b}")
    print(f"Surgical Urgency: {eval_b.surgical_triage_urgency}")
    print(f"Procedure: {eval_b.surgical_procedure_recommendation}")