Specificity of the Occlusion Myocardial Infarction-Trained PMcardio “Queen of Hearts” AI-ECG in Inflammatory Myopericardial Syndromes

Figures

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  Figure 1. Study Flow Chart and Patient Selection Flow diagram showing the screening, exclusion, and inclusion process of patients presenting with suspected IMPS. Among 393 screened patients, 151 were excluded for predefined criteria, including missing data, lack of confirmatory imaging, alternative diagnoses, incomplete ECGs, or missing informed consent. A total of 242 IMPS-only patients were included and categorized into (myo)pericarditis and (peri)myocarditis subgroups according to diagnostic work-up with cardiac magnetic resonance imaging and/or coronary angiography. Subgroup distributions and diagnostic modalities are detailed. ESC = European Society of Cardiology; IMPS = inflammatory myopericardial syndromes; MINOCA = myocardial infarction with non-obstructive coronary arteries; SCAD = spontaneous coronary artery dissection.

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  Figure 2. Specificity of Queen of Hearts versus Alternative Criteria Comparative specificity of Queen of Hearts vs alternative criteria for non-OMI classification in the IMPS cohort. The left panel displays specificity, representing the proportion of IMPS patients correctly identified as not having OMI. The right panel shows false-positive rates, representing the proportion of IMPS patients incorrectly classified as OMI. Dashed lines indicate clinically relevant thresholds (green: 95% specificity/5% false-positive rate; orange: 90% specificity/10% false-positive rate). 4-Var = 4-variable score; ESC = European Society of Cardiology; IMPS = inflammatory myopericardial syndromes; OMI = occlusion myocardial infarction (encompassing ST-elevation myocardial infarction and ST-elevation myocardial infarction-like pattern); QoH denotes Queen of Hearts.

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  Figure 3. Specificity of Queen of Hearts versus Large Language Model The left panel displays specificity, representing the proportion of IMPS patients correctly identified as not having OMI. The right panel shows false-positive rates, representing the proportion of IMPS patients incorrectly classified as OMI. Dashed lines indicate clinically relevant thresholds (green: 95% specificity/5% false-positive rate; orange: 90% specificity/10% false-positive rate). IMPS = inflammatory myopericardial syndromes; OMI = occlusion myocardial infarction (encompassing ST-elevation myocardial infarction and ST-elevation myocardial infarction-like pattern); QoH = Queen of Hearts.

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  Figure 4. Representative Discordant ESC-Positive/QoH-Negative ECGs Representative ECGs from discordant cases meeting ESC STEMI ECG criteria but classified as non-OMI by QoH. Despite extensive STE involving anterior, inferior, and/or lateral leads (A to D), straight or partially convex ST morphology (A and C), and bifid ST morphology in V3-V4 (C), QoH likely favored benign inflammatory features, including predominantly concave ST morphology (A to D), terminal-QRS notching (A, B, and D), preserved R-wave progression (A to D), absence of clear territorial distribution (A, B, and D), subtle PR-segment depression and positive Spodick sign (B), and lack of reciprocal ST-segment depression (A to D). ESC = European Society of Cardiology; QoH = Queen of Hearts; STEMI = ST-segment elevation myocardial infarction; OMI = occlusion myocardial infarction; STE = ST-segment elevation.

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  Figure 5. Representative Discordant QoH-Positive/ESC-Negative ECGs Representative ECGs from discordant cases classified as OMI by QoH but not meeting ESC STEMI ECG criteria. Despite the absence of ESC STEMI ECG criteria (A to C), heatmap activation highlighted subtle or borderline repolarization abnormalities, including localized inframillimetric anterior STE with concave morphology (A), inferior territory submillimetric STE with J-point notching (B), and lateral J-point notching with associated inferior ST-segment depression and T-wave inversion (C). Additional features included relative T-wave prominence (A to C) and low QRS-to-T amplitude contrast (A and B). ESC = European Society of Cardiology; QoH = Queen of Hearts.

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  Central Illustration. Specificity of Queen of Hearts AI-ECG in Inflammatory Myopericardial Syndromes This retrospective single-center study evaluated the ECG-level specificity of the PMcardio Queen of Hearts (QoH) artificial intelligence (AI) ECG model for correctly classifying inflammatory myopericardial syndromes (IMPS) ECGs as nonocclusion myocardial infarction (OMI) in patients with acute chest pain. A total of 242 IMPS patients were included. When applied as an ECG-only tool, QoH demonstrated high overall specificity (95.0%), with fewer false-positive classifications than ESC STEMI ECG criteria, the 4-variable formula, and general-purpose large language models. Specificity was higher in (myo)pericarditis than in (peri)myocarditis and showed modest variation across ECG territories. Prospective studies are warranted to define sensitivity and to evaluate the potential impact of QoH on clinical decision-making and outcomes in patients with suspected IMPS. LLM = large language model.