test_rules.py

import json

def calculate_ischemic_risk(p):
    return (p['troponin'] == 1 or 
            p['ischemicInstability'] == 1 or 
            p['ischemicAngina'] == 1 or 
            p['ischemicHeartFailure'] == 1 or 
            p['ischemicArrhythmia'] == 1)

def calculate_bleeding_risk(p):
    return (p['age'] >= 75 or 
            p['bleedingRenal'] == 1 or 
            p['bleedingAnemia'] == 1 or 
            p['bleedingAF'] == 1 or 
            p['bleedingStroke'] == 1)

def evaluate_rules(p):
    is_high_ischemic = calculate_ischemic_risk(p)
    is_high_bleeding = calculate_bleeding_risk(p)
    
    results = {
        'deviations': [],
        'alerts': [],
        'regimen': []
    }
    
    # 1. Oxygenation Check
    if 'spo2' in p and p['spo2'] < 90:
        results['alerts'].append("HYPOXEMIA ALERT: Patient SpO2 < 90%. Administer supplementary oxygen immediately.")
        
    # 2. Reperfusion Strategy vs Antiplatelet Mapping Rules
    dx = p['diagnosis']
    reperfusion = p['reperfusion']
    p2y12 = p['p2y12']
    age_flag = 1 if p['age'] >= 75 else 0
    sbp = p.get('sbp', 120)
    
    # Calculate Table 7 antiplatelet recommendations
    asp_ld = "162–325 mg orally (chewed)"
    asp_md = "75–100 mg orally once daily"
    aspirin_rec = f"Aspirin [Loading: {asp_ld}, Maintenance: {asp_md}]"
    
    p2y12_name = "None Selected"
    p2y12_ld = "N/A"
    p2y12_md = "N/A"
    p2y12_adj = "None"
    p2y12_warn = ""
    
    age = p.get('age', 60)
    weight = p.get('weight', 70)
    
    is_stemi = (dx == 1)
    is_fibrinolysis = (reperfusion == 2)
    is_pci = (reperfusion == 1)
    
    if p2y12 == 1:
        p2y12_name = "Clopidogrel"
        if is_stemi and is_fibrinolysis:
            if age < 75:
                p2y12_ld = "300 mg orally"
                p2y12_md = "75 mg orally daily"
            else:
                p2y12_ld = "No loading dose (initial dose 75 mg orally)"
                p2y12_md = "75 mg orally daily"
                p2y12_adj = "Loading dose is omitted because the patient is older than 75 years."
        else:
            p2y12_ld = "300–600 mg orally"
            p2y12_md = "75 mg orally daily"
    elif p2y12 == 2:
        p2y12_name = "Ticagrelor"
        p2y12_ld = "180 mg orally"
        p2y12_md = "90 mg orally twice daily"
        if is_stemi and is_fibrinolysis:
            p2y12_warn = "WARNING: Ticagrelor is not preferred post-fibrinolysis according to clinical guidelines."
    elif p2y12 == 3:
        p2y12_name = "Prasugrel"
        p2y12_ld = "60 mg orally"
        if is_fibrinolysis:
            p2y12_md = "N/A"
            p2y12_warn = "WARNING: Prasugrel is contraindicated with Fibrinolytic therapy."
        elif not is_pci:
            p2y12_md = "10 mg orally daily (Not recommended for non-PCI)"
            p2y12_warn = "WARNING: Prasugrel should only be used in patients undergoing PCI."
        else:
            if weight >= 60 and age < 75:
                p2y12_md = "10 mg orally daily"
            else:
                p2y12_md = "5 mg orally daily"
                p2y12_adj = f"Maintenance dose is reduced to 5 mg daily due to {'age ≥ 75' if age >= 75 else ''}{' and ' if age >= 75 and weight < 60 else ''}{'weight < 60 kg' if weight < 60 else ''}."
                p2y12_warn = f"CAUTION: Maintenance dose is reduced to 5 mg daily because of {'age ≥ 75' if age >= 75 else ''}{' or ' if age >= 75 or weight < 60 else ''}{'body weight < 60 kg' if weight < 60 else ''}."
    
    p2y12_rec = f"{p2y12_name} [Loading: {p2y12_ld}, Maintenance: {p2y12_md}"
    if p2y12_adj != "None":
        p2y12_rec += f", Adjustment: {p2y12_adj}"
    p2y12_rec += "]"
    
    if p2y12_warn:
        results['alerts'].append(p2y12_warn)

    if dx == 1: # STEMI
        if reperfusion == 2: # Fibrinolytics
            # Fibrinolytic contraindications (Table 14)
            if sbp > 180:
                results['alerts'].append("CRITICAL: Absolute contraindication for Fibrinolysis (Severe uncontrolled SBP > 180 mmHg).")
                results['deviations'].append("CONTRAINDICATION FAULT: Fibrinolysis selected despite SBP > 180 mmHg.")
            if p.get('bleedingStroke', 0) == 1 or p.get('priorStroke', 0) == 1:
                results['alerts'].append("CRITICAL: Absolute contraindication for Fibrinolysis (History of Stroke/TIA).")
                results['deviations'].append("CONTRAINDICATION FAULT: Fibrinolysis selected in patient with prior Stroke/TIA.")
            if p.get('bleedingAF', 0) == 1 or p.get('concurrentOac', 0) == 1:
                results['alerts'].append("WARNING: Relative contraindication for Fibrinolysis (Oral Anticoagulant therapy).")
            if p.get('pepticUlcer', 0) == 1:
                results['alerts'].append("WARNING: Relative contraindication for Fibrinolysis (Active peptic ulcer).")
            if p.get('dementia', 0) == 1:
                results['alerts'].append("WARNING: Relative contraindication for Fibrinolysis (Dementia).")

            results['regimen'].append(aspirin_rec)
            results['regimen'].append(p2y12_rec)
                
            if p2y12 in [2, 3]:
                results['deviations'].append("CRITICAL MISMATCH: Potent antiplatelets (Prasugrel/Ticagrelor) run concurrently with Fibrinolytics.")
                results['alerts'].append("HEMORRHAGE RISK HIGH: Discontinue Prasugrel/Ticagrelor immediately to mitigate intracranial bleeding risk.")
        elif reperfusion == 1: # Primary PCI
            results['regimen'].append(aspirin_rec)
            results['regimen'].append(p2y12_rec)
            if p2y12 == 1 and not is_high_bleeding:
                results['deviations'].append("SUBOPTIMAL PROTECTION: Clopidogrel used in standard risk PPCI path.")
                results['alerts'].append("EFFICACY WARNING: Upgrade to Ticagrelor or Prasugrel for superior protection against stent thrombosis.")
            elif p2y12 == 0:
                results['deviations'].append("CRITICAL OMISSION: A P2Y12 inhibitor is required for all STEMI patients undergoing Primary PCI.")
    elif dx in [2, 3]: # NSTE-ACS
        # Relative contraindications to routine invasive strategy (Table 15)
        has_invasive_contra = (is_high_bleeding or p.get('thrombocytopenia', 0) == 1 or p.get('bleedingRenal', 0) == 1 or p.get('arf', 0) == 1 or p.get('expectancy', 0) == 1 or p.get('dementia', 0) == 1)
        
        if has_invasive_contra:
            results['alerts'].append("RELATIVE CONTRAINDICATION: Routine invasive procedure has contraindications (due to HBR, thrombocytopenia, CKD/ARF, limited expectancy, or dementia). Route to Conservative Medical Management instead.")
            if reperfusion == 1:
                results['deviations'].append("CONTRAINDICATION FAULT: Routine invasive procedure selected despite relative contraindications.")

        if reperfusion == 4: # Conservative Medical Management
            results['regimen'].append(aspirin_rec)
            results['regimen'].append(p2y12_rec)
            if p2y12 == 1 and not is_high_bleeding:
                results['deviations'].append("NON-PREFERENTIAL REGIMEN: Clopidogrel selected for standard risk medical management.")
        elif reperfusion == 1: # Invasive Strategy
            results['regimen'].append(aspirin_rec)
            results['regimen'].append(p2y12_rec)
            if p2y12 == 1 and not is_high_bleeding:
                results['deviations'].append("SUBOPTIMAL EFFICACY: Clopidogrel is less effective than Ticagrelor/Prasugrel. Switch to a high-potency agent unless contraindicated or high bleeding risk exists.")
                
    # 3. NSTE-ACS Invasive Strategy Timing
    if dx in [2, 3]:
        if is_high_ischemic:
            results['alerts'].append("CRITICAL: Immediate Invasive Strategy Required (Angiography within 2 hours) due to presence of High Ischemic Risk Indicators (cardiogenic shock, refractory angina, heart failure, or sustained VT/VF).")
        else:
            results['regimen'].append("Guideline Compliant: Early Invasive Strategy (Angiography within 24 hours) is indicated for standard-risk NSTE-ACS.")
            
    # 4. Baseline Pharmacotherapy Checks (Anticoagulation, Beta-Blockers, RAAS)
    if p.get('anticoagulation', 0) == 0:
        results['deviations'].append("OMISSION FAULT: Parenteral anticoagulation not administered.")
        results['regimen'].append("Initiate Parenteral Anticoagulation (UFH, Enoxaparin, Bivalirudin, or Fondaparinux).")
        
    if p.get('betaBlocker', 0) == 0:
        results['deviations'].append("OMISSION FAULT: Baseline Beta-Blocker therapy not initiated.")
        results['regimen'].append("Initiate Oral Beta-Blocker therapy (e.g., Metoprolol succinate or Carvedilol) within 24 hours.")
        
    if p.get('raasInhibitor', 0) == 0:
        results['deviations'].append("OMISSION FAULT: Baseline RAAS Inhibitor (ACEI/ARB) not initiated.")
        results['regimen'].append("Initiate ACE Inhibitor (e.g., Ramipril) or ARB (e.g., Valsartan) within 24 hours.")

    # 5. RBC Transfusion Protocol
    if p.get('bleedingAnemia', 0) == 1 and p.get('minorBleeding', 0) == 0:
        if p.get('transfusion', 0) == 0:
            results['deviations'].append("OMISSION FAULT: RBC transfusion not administered despite severe anemia without active bleeding.")
            results['regimen'].append("Administer RBC Transfusion to maintain hemoglobin target of 10 g/dL (Class 2b).")
        else:
            results['regimen'].append("Guideline Compliant: RBC Transfusion administered to maintain Hb target (10 g/dL).")

    # 6. High Bleeding Risk (HBR) Custom Safe-Overrides
    if is_high_bleeding:
        if p2y12 == 3: # Prasugrel in HBR
            results['deviations'].append("CONTRAINDICATION OVERRIDE: Prasugrel allocated within high bleeding risk profile.")
            results['alerts'].append("STOP SIGN: Immediately discontinue Prasugrel. Substitute with Clopidogrel 75mg daily.")
            
        # Rules A, B, C
        if p.get('concurrentOac', 0) == 1 or p['bleedingAF'] == 1: # Rule C
            results['regimen'].append("Convert to Dual Therapy (OAC + Clopidogrel 75mg) after 1-4 weeks; completely drop Aspirin.")
        elif p.get('minorBleeding', 0) == 1: # Rule B
            results['regimen'].append("P2Y12 Down-Titration: Transition from Ticagrelor/Prasugrel to Clopidogrel 75mg daily due to bleeding/Hb drop.")
        else: # Rule A
            results['regimen'].append("Short-Course DAPT: Transition to Ticagrelor Monotherapy after 1-3 months, completely dropping Aspirin.")
            
    # 7. GI Safety Net
    has_gi_trigger = is_high_bleeding or p.get('pepticUlcer', 0) == 1 or p['age'] >= 75 or p.get('nsaid', 0) == 1
    if has_gi_trigger:
        if p.get('ppiPrescribed', 0) != 1:
            results['alerts'].append("GASTRIC GAP: Co-prescribe a protective PPI (e.g., Pantoprazole) to manage GI bleeding margins.")
        
        if p2y12 == 1 and p.get('ppiPrescribed', 0) == 1:
            results['alerts'].append("PPI Metabolic Optimization: If Clopidogrel is prescribed, Pantoprazole is preferred over Omeprazole (prevents CYP2C19 inhibition).")
            
    # 8. Lipid Secondary Prevention
    if p['statin'] != 2:
        results['deviations'].append("OMISSION FAULT: Patient not initiated on baseline High-Intensity Statin therapy.")
        results['regimen'].append("Initiate High-Intensity Atorvastatin 40-80mg or Rosuvastatin 20-40mg.")
        
    if p['ldlc'] >= 70:
        results['deviations'].append("LIPID GOAL MISSED: Follow-up LDL tracking >= 70 mg/dL.")
        results['regimen'].append("Add Non-Statin Therapy: Append Ezetimibe 10mg daily immediately (Class 1).")
    elif 55 <= p['ldlc'] < 70:
        results['regimen'].append("Therapeutic Optimization: Evaluate addition of Ezetimibe to reach target < 55 mg/dL (Class 2a).")
        
    return results

def run_tests():
    # Load converted patients
    with open('patients.json', 'r', encoding='utf-8') as f:
        patients = json.load(f)
        
    print(f"Loaded {len(patients)} patients for rule audit tests.")
    
    # Test cases count
    criticals = 0
    warnings = 0
    
    for i, p in enumerate(patients):
        res = evaluate_rules(p)
        criticals += len(res['deviations'])
        warnings += len(res['alerts'])
                
    print(f"Audit Summary of Converted Registry Dataset:")
    print(f"  - Total Patients Audited: {len(patients)}")
    print(f"  - Total Deviations/Omissions found: {criticals}")
    print(f"  - Total Safety Alerts triggered: {warnings}")
    
    # Run test profiles
    print("\nRunning specific guideline boundary checks:")
    
    # Boundary Test 1: STEMI + Fibrinolytics + Ticagrelor
    test1 = {
        "patientId": "T1", "name": "Test STEMI Fibrinolytic Ticagrelor",
        "age": 60, "gender": "Male", "diagnosis": 1, "troponin": 1, "ecg": 1,
        "ischemicInstability": 0, "ischemicAngina": 0, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 0, "bleedingAnemia": 0, "bleedingAF": 0, "bleedingStroke": 0,
        "spo2": 95, "sbp": 120, "hr": 80, "cpType": 1,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 0, "concurrentOac": 0, "ppiPrescribed": 0,
        "reperfusion": 2, "p2y12": 2, "statin": 2, "ldlc": 65
    }
    r1 = evaluate_rules(test1)
    assert any("CRITICAL MISMATCH" in d for d in r1['deviations']), f"Failed Test 1: {r1}"
    print("  [PASS] STEMI post-fibrinolysis on Ticagrelor correctly flagged as CRITICAL MISMATCH.")
    
    # Boundary Test 1b: STEMI + Fibrinolytics + Clopidogrel + Age >= 75
    test1b = {
        "patientId": "T1b", "name": "Test STEMI Fibrinolytic Clopidogrel >=75",
        "age": 75, "gender": "Male", "diagnosis": 1, "troponin": 1, "ecg": 1,
        "ischemicInstability": 0, "ischemicAngina": 0, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 0, "bleedingAnemia": 0, "bleedingAF": 0, "bleedingStroke": 0,
        "spo2": 95, "sbp": 120, "hr": 80, "cpType": 1,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 0, "concurrentOac": 0, "ppiPrescribed": 1,
        "reperfusion": 2, "p2y12": 1, "statin": 2, "ldlc": 65
    }
    r1b = evaluate_rules(test1b)
    assert any("no load" in reg.lower() for reg in r1b['regimen']), f"Failed Test 1b: {r1b}"
    print("  [PASS] STEMI post-fibrinolysis Clopidogrel (Age >= 75) correctly flags for no loading dose.")

    # Boundary Test 2: NSTE-ACS + Ischemic Indicators (Angiography within 2 hours)
    test2 = {
        "patientId": "T2", "name": "Test NSTE-ACS High Ischemic",
        "age": 60, "gender": "Male", "diagnosis": 2, "troponin": 1, "ecg": 2,
        "ischemicInstability": 0, "ischemicAngina": 1, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 0, "bleedingAnemia": 0, "bleedingAF": 0, "bleedingStroke": 0,
        "spo2": 95, "sbp": 120, "hr": 80, "cpType": 1,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 0, "concurrentOac": 0, "ppiPrescribed": 0,
        "reperfusion": 4, "p2y12": 1, "statin": 2, "ldlc": 65
    }
    r2 = evaluate_rules(test2)
    assert any("Immediate Invasive Strategy Required" in a for a in r2['alerts']), f"Failed Test 2: {r2}"
    print("  [PASS] High Ischemic Risk NSTE-ACS patient correctly flagged for Immediate Invasive Strategy.")
    
    # Boundary Test 3: HBR + Prasugrel (Absolute Contraindication)
    test3 = {
        "patientId": "T3", "name": "Test HBR Prasugrel",
        "age": 76, "gender": "Male", "diagnosis": 1, "troponin": 1, "ecg": 1,
        "ischemicInstability": 0, "ischemicAngina": 0, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 0, "bleedingAnemia": 0, "bleedingAF": 0, "bleedingStroke": 0,
        "spo2": 95, "sbp": 120, "hr": 80, "cpType": 1,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 0, "concurrentOac": 0, "ppiPrescribed": 1,
        "reperfusion": 1, "p2y12": 3, "statin": 2, "ldlc": 65
    }
    r3 = evaluate_rules(test3)
    assert any("CONTRAINDICATION OVERRIDE" in d for d in r3['deviations']), f"Failed Test 3: {r3}"
    print("  [PASS] HBR patient (Age >= 75) on Prasugrel correctly flagged as CONTRAINDICATION OVERRIDE.")
    
    # Boundary Test 4: PPI Gastric Gap & Metabolic Optimization
    test4 = {
        "patientId": "T4", "name": "Test Gastric Gap and Metabolic",
        "age": 78, "gender": "Male", "diagnosis": 3, "troponin": 0, "ecg": 0,
        "ischemicInstability": 0, "ischemicAngina": 0, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 0, "bleedingAnemia": 0, "bleedingAF": 0, "bleedingStroke": 0,
        "spo2": 95, "sbp": 120, "hr": 80, "cpType": 2,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 0, "concurrentOac": 0, "ppiPrescribed": 0,
        "reperfusion": 4, "p2y12": 1, "statin": 2, "ldlc": 65
    }
    r4 = evaluate_rules(test4)
    assert any("GASTRIC GAP" in a for a in r4['alerts']), f"Failed Test 4 Gastric Gap: {r4}"
    
    test4['ppiPrescribed'] = 1
    r4b = evaluate_rules(test4)
    assert any("PPI Metabolic Optimization" in a for a in r4b['alerts']), f"Failed Test 4 Metabolic: {r4b}"
    print("  [PASS] PPI Gastric Gap and CYP2C19 metabolic drug interaction rules verified.")

    # Boundary Test 5: Hypoxemia check
    test5 = {
        "patientId": "T5", "name": "Test Hypoxemia",
        "age": 60, "gender": "Male", "diagnosis": 3, "troponin": 0, "ecg": 0,
        "ischemicInstability": 0, "ischemicAngina": 0, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 0, "bleedingAnemia": 0, "bleedingAF": 0, "bleedingStroke": 0,
        "spo2": 88, "sbp": 120, "hr": 80, "cpType": 2,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 0, "concurrentOac": 0, "ppiPrescribed": 0,
        "reperfusion": 4, "p2y12": 1, "statin": 2, "ldlc": 65
    }
    r5 = evaluate_rules(test5)
    assert any("HYPOXEMIA ALERT" in a for a in r5['alerts']), f"Failed Test 5 Hypoxemia: {r5}"
    print("  [PASS] Hypoxemia (SpO2 < 90%) check verified.")

    # Boundary Test 6: HBR Rules A/B/C
    # Rule B: Minor Bleeding
    test6b = {
        "patientId": "T6b", "name": "Test Rule B",
        "age": 60, "gender": "Male", "diagnosis": 3, "troponin": 0, "ecg": 0,
        "ischemicInstability": 0, "ischemicAngina": 0, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 1, "bleedingAnemia": 0, "bleedingAF": 0, "bleedingStroke": 0,
        "spo2": 95, "sbp": 120, "hr": 80, "cpType": 2,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 1, "concurrentOac": 0, "ppiPrescribed": 1,
        "reperfusion": 4, "p2y12": 2, "statin": 2, "ldlc": 65
    }
    r6b = evaluate_rules(test6b)
    assert any("P2Y12 Down-Titration" in reg for reg in r6b['regimen']), f"Failed Rule B: {r6b}"
    print("  [PASS] HBR Rule B (P2Y12 Down-Titration on minor bleed) verified.")

    # Rule C: Concurrent OAC
    test6c = {
        "patientId": "T6c", "name": "Test Rule C",
        "age": 60, "gender": "Male", "diagnosis": 3, "troponin": 0, "ecg": 0,
        "ischemicInstability": 0, "ischemicAngina": 0, "ischemicHeartFailure": 0, "ischemicArrhythmia": 0,
        "bleedingRenal": 1, "bleedingAnemia": 0, "bleedingAF": 1, "bleedingStroke": 0,
        "spo2": 95, "sbp": 120, "hr": 80, "cpType": 2,
        "diabetes": 0, "ckd": 0, "priorStroke": 0, "pepticUlcer": 0, "nsaid": 0,
        "minorBleeding": 0, "concurrentOac": 1, "ppiPrescribed": 1,
        "reperfusion": 4, "p2y12": 2, "statin": 2, "ldlc": 65
    }
    r6c = evaluate_rules(test6c)
    assert any("Convert to Dual Therapy" in reg for reg in r6c['regimen']), f"Failed Rule C: {r6c}"
    print("  [PASS] HBR Rule C (Triple to Dual therapy conversion for OAC) verified.")
    
    print("\nAll boundary tests PASSED successfully.")

if __name__ == "__main__":
    run_tests()