Artificial intelligence-enabled sinus electrocardiograms for the detection of paroxysmal atrial fibrillation benchmarked against the CHARGE-AF score

Aims We aimed to develop and externally validate a convolutional neural network (CNN) using sinus rhythm electrocardiograms (ECGs) and CHARGE-AF features to predict incident paroxysmal atrial fibrillation (AF), benchmarking its performance against the CHARGE-AF score. Methods and Results We curated 157,192 sinus ECGs from 76,986 patients within the NYU Langone Health system, splitting data into training, validation, and test sets. Two cohorts, from suburban U.S. outpatient practices and Greek tertiary hospitals, were used for external validation. The model utilizing the sinus ECG signal and all CHARGE-AF features achieved the highest test set AUC (0.89) and AUPRC (0.69), outperforming the CHARGE-AF score alone. Model robustness was maintained in the external U.S. cohort (AUC 0.90, AUPRC 0.67) and the European cohort (AUC 0.85, AUPRC 0.78). Subgroup analyses confirmed consistent performance across age, sex, and race strata. A CNN using ECG signals alone retained strong predictive ability, particularly when simulating missing or inaccurate clinical data. Conclusions Our CNN integrating sinus rhythm ECGs and CHARGE-AF features demonstrated superior predictive performance over traditional risk scoring alone for detecting incident paroxysmal AF. The model maintained accuracy across geographically and clinically diverse external validation cohorts, supporting its potential for broad implementation in AF screening strategies.