Key result
ECG deep learning attribution methods show limited reliability and high variability, challenging clinical trustworthiness.
Why the study?
To be clinically useful, attribution-based explainability methods for deep neural networks in ECG analysis must produce explanations that are clear and truly reflect the model inner workings.
Commonly used AI explainability attribution methods for ECG interpretation are unreliable and unstable, highlighting the need for task-specific sanity checks before trusting their outputs in clinical settings.
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Current attribution methods should not guide clinical ECG AI decisions; leaves open need for validated explainability standards.
Background and Aims Attribution-based explainability methods are widely used in electrocardiogram (ECG) analysis to interpret predictions from “black-box” deep neural networks (DNNs). To be useful in clinical applications, attribution methods must produce explanations that are both clear and reflective of the model’s inner workings. This study evaluates 12 attribution methods in DNN-based ECG classification. Methods We analysed 12 attribution methods using a dataset of 873,710 median beat ECGs spanning nine diagnostic classes. Methods were applied to convolutional neural network-based models trained for ECG classification. Performance was evaluated across four experiments: inter-method similarity, self-consistency, dependence on model weights, and ability to identify features important for model inference. Results All task models achieved an area under the receiver operating curve above 0.95. Attribution methods demonstrated low correlation and high variability across inter-method comparisons. Self-consistency across random model initialisations was moderate for most methods (mean correlation 0.41–0.65). Randomising model weights led to rapid loss of correlation, although some methods did not converge to zero. Perturbation of input data revealed differences in how well attribution methods identified features relevant to model performance. Conclusions Attribution methods demonstrated limited reliability, instability across model variants and incomplete dependence on learned parameters, constraining their utility in high-stakes settings such as healthcare. These findings suggest that attribution techniques should be used cautiously and supported by task-specific sanity checks. Approaches grounded in rigorous validation, inherently interpretable modelling or counterfactual explanations may better support clinically meaningful insight.
Arends et al. (2026) studied Patients with resting 12-lead ECGs spanning nine diagnostic classes (n=192,257). 12 attribution-based explainability methods for deep neural networks was evaluated on Inter-method similarity, self-consistency across model initialisations, dependence on model weights, and ability to identify important features. Attribution methods applied to deep neural networks for ECG classification demonstrated limited reliability, high variability across methods, and moderate self-consistency (mean correlation 0.41–0.65), limiting their clinical trustworthiness.
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