November 18, 2024European Heart Journal - Digital Health16 citationsOpen Access
View Full PaperA comparison of artificial intelligence–enhanced electrocardiography approaches for the prediction of time to mortality using electrocardiogram images
Key Result
Image 2D CNN and digitized 1D CNN models enabled mortality prediction from ECG images with comparable performance to natively digital 1D CNN models (C-index 0.780 vs 0.775).
Study Design
Type
Cohort (n=835,934)
Multicenter
Yes
Structured PICO
Do AI-ECG models trained on ECG images perform comparably to models trained on natively digital ECGs for predicting mortality?
P
Population
189,539 patients from a secondary care dataset, with external validation in 645,373 patients from a Brazilian primary care cohort and 1,022 patients from a Chagas disease cohort
I
Intervention
Image 2D CNN model and digitized 1D CNN model for mortality prediction from ECG images
C
Comparator
Natively digital 1D CNN model
O
Outcome
Prediction of time to mortality (measured by C-index)surrogate
AI-ECG models can accurately predict mortality using ECG images, performing comparably to models using natively digital ECGs, which enables their use in settings lacking digital ECG infrastructure.
Main Result
Effect estimate: C-index 0.780 (95% CI 0.779-0.781)
Absolute Event Rate: 0.78% vs 0.775%
Abstract
Abstract Aims Most artificial intelligence-enhanced electrocardiogram (AI-ECG) models used to predict adverse events including death require that the ECGs be stored digitally. However, the majority of clinical facilities worldwide store ECGs as images. Methods and results A total of 1 163 401 ECGs (189 539 patients) from a secondary care data set were available as both natively digital traces and PDF images. A digitization pipeline extracted signals from PDFs. Separate 1D convolutional neural network (CNN) models were trained on natively digital or digitized ECGs, with a discrete-time survival loss function to predict time to mortality. A 2D CNN model was trained on 310 × 868 px ECG images. External validation was performed in 958 954 ECGs (645 373 patients) from a Brazilian primary care cohort and 1022 ECGs (1022 patients) from a Chagas disease cohort. The image 2D CNN model and digitized 1D CNN model performed comparably to natively digital 1D CNN model in internal C-index 0.780 (0.779–0.781), 0.772 (0.771–0.774), and 0.775 (0.774–0.776), respectively and external validation. Models trained on natively digital 1D ECGs had comparable performance when applied to digitized 1D ECGs C-index 0.773 (0.771–0.774). Conclusion Both the image 2D CNN and digitized 1D CNN enable mortality prediction from ECG images, with comparable performance to natively digital 1D CNN. Models trained on natively digital 1D ECGs can also be applied to digitized 1D ECGs, without any significant loss in performance. This work allows AI-ECG mortality prediction to be applied in diverse global settings lacking digital ECG infrastructure.