Advances in cardiac pacing with leadless pacemakers and conduction system pacing.

PURPOSE OF REVIEW: The field of cardiac pacing has undergone significant evolution with the introduction and adoption of conduction system pacing (CSP) and leadless pacemakers (LLPMs). These innovations provide benefits over conventional pacing methods including avoiding lead related complications and achieving more physiological cardiac activation. This review critically assesses the latest advancements in CSP and LLPMs, including their benefits, challenges, and potential for future growth. RECENT FINDINGS: CSP, especially of the left bundle branch area, enhances ventricular depolarization and cardiac mechanics. Recent studies show CSP to be favorable over traditional pacing in various patient populations, with an increase in its global adoption. Nevertheless, challenges related to lead placement and long-term maintenance persist. Meanwhile, LLPMs have emerged in response to complications from conventional pacemaker leads. Two main types, Aveir and Micra, have demonstrated improved outcomes and adoption over time. The incorporation of new technologies allows LLPMs to cater to broader patient groups, and their integration with CSP techniques offers exciting potential. SUMMARY: The advancements in CSP and LLPMs present a transformative shift in cardiac pacing, with evidence pointing towards enhanced clinical outcomes and reduced complications. Future innovations and research are likely to further elevate the clinical impact of these technologies, ensuring improved patient care for those with conduction system disorders.

Artificial Intelligence in Cardiovascular Disease Prevention: Is it Ready for Prime Time?

PURPOSE OF REVIEW: This review evaluates how Artificial Intelligence (AI) enhances atherosclerotic cardiovascular disease (ASCVD) risk assessment, allows for opportunistic screening, and improves adherence to guidelines through the analysis of unstructured clinical data and patient-generated data. Additionally, it discusses strategies for integrating AI into clinical practice in preventive cardiology. RECENT FINDINGS: AI models have shown superior performance in personalized ASCVD risk evaluations compared to traditional risk scores. These models now support automated detection of ASCVD risk markers, including coronary artery calcium (CAC), across various imaging modalities such as dedicated ECG-gated CT scans, chest X-rays, mammograms, coronary angiography, and non-gated chest CT scans. Moreover, large language model (LLM) pipelines are effective in identifying and addressing gaps and disparities in ASCVD preventive care, and can also enhance patient education. AI applications are proving invaluable in preventing and managing ASCVD and are primed for clinical use, provided they are implemented within well-regulated, iterative clinical pathways.

AKI in Hospitalized Patients with COVID-19.

BACKGROUND: Early reports indicate that AKI is common among patients with coronavirus disease 2019 (COVID-19) and associated with worse outcomes. However, AKI among hospitalized patients with COVID-19 in the United States is not well described. METHODS: This retrospective, observational study involved a review of data from electronic health records of patients aged ≥18 years with laboratory-confirmed COVID-19 admitted to the Mount Sinai Health System from February 27 to May 30, 2020. We describe the frequency of AKI and dialysis requirement, AKI recovery, and adjusted odds ratios (aORs) with mortality. RESULTS: Of 3993 hospitalized patients with COVID-19, AKI occurred in 1835 (46%) patients; 347 (19%) of the patients with AKI required dialysis. The proportions with stages 1, 2, or 3 AKI were 39%, 19%, and 42%, respectively. A total of 976 (24%) patients were admitted to intensive care, and 745 (76%) experienced AKI. Of the 435 patients with AKI and urine studies, 84% had proteinuria, 81% had hematuria, and 60% had leukocyturia. Independent predictors of severe AKI were CKD, men, and higher serum potassium at admission. In-hospital mortality was 50% among patients with AKI versus 8% among those without AKI (aOR, 9.2; 95% confidence interval, 7.5 to 11.3). Of survivors with AKI who were discharged, 35% had not recovered to baseline kidney function by the time of discharge. An additional 28 of 77 (36%) patients who had not recovered kidney function at discharge did so on posthospital follow-up. CONCLUSIONS: AKI is common among patients hospitalized with COVID-19 and is associated with high mortality. Of all patients with AKI, only 30% survived with recovery of kidney function by the time of discharge.

Blood Donation and COVID-19: Reconsidering the 3-Month Deferral Policy for Gay, Bisexual, Transgender, and Other Men Who Have Sex With Men.

In April 2020, in light of COVID-19-related blood shortages, the US Food and Drug Administration (FDA) reduced the deferral period for men who have sex with men (MSM) from its previous duration of 1 year to 3 months.Although originally born out of necessity, the decades-old restrictions on MSM donors have been mitigated by significant advancements in HIV screening, treatment, and public education. The severity of the ongoing COVID-19 pandemic-and the urgent need for safe blood products to respond to such crises-demands an immediate reconsideration of the 3-month deferral policy for MSM.We review historical HIV testing and transmission evidence, discuss the ethical ramifications of the current deferral period, and examine the issue of noncompliance with donor deferral rules. We also propose an eligibility screening format that involves an individual risk-based screening protocol and, unlike current FDA guidelines, does not effectively exclude donors on the basis of gender identity or sexual orientation. Our policy proposal would allow historically marginalized community members to participate with dignity in the blood donation process without compromising blood donation and transfusion safety outcomes.

Deep learning and the electrocardiogram: review of the current state-of-the-art.

In the recent decade, deep learning, a subset of artificial intelligence and machine learning, has been used to identify patterns in big healthcare datasets for disease phenotyping, event predictions, and complex decision making. Public datasets for electrocardiograms (ECGs) have existed since the 1980s and have been used for very specific tasks in cardiology, such as arrhythmia, ischemia, and cardiomyopathy detection. Recently, private institutions have begun curating large ECG databases that are orders of magnitude larger than the public databases for ingestion by deep learning models. These efforts have demonstrated not only improved performance and generalizability in these aforementioned tasks but also application to novel clinical scenarios. This review focuses on orienting the clinician towards fundamental tenets of deep learning, state-of-the-art prior to its use for ECG analysis, and current applications of deep learning on ECGs, as well as their limitations and future areas of improvement.

Coronavirus 2019 and People Living With Human Immunodeficiency Virus: Outcomes for Hospitalized Patients in New York City.

BACKGROUND: There are limited data regarding the clinical impact of coronavirus disease 2019 (COVID-19) on people living with human immunodeficiency virus (PLWH). In this study, we compared outcomes for PLWH with COVID-19 to a matched comparison group. METHODS: We identified 88 PLWH hospitalized with laboratory-confirmed COVID-19 in our hospital system in New York City between 12 March and 23 April 2020. We collected data on baseline clinical characteristics, laboratory values, HIV status, treatment, and outcomes from this group and matched comparators (1 PLWH to up to 5 patients by age, sex, race/ethnicity, and calendar week of infection). We compared clinical characteristics and outcomes (death, mechanical ventilation, hospital discharge) for these groups, as well as cumulative incidence of death by HIV status. RESULTS: Patients did not differ significantly by HIV status by age, sex, or race/ethnicity due to the matching algorithm. PLWH hospitalized with COVID-19 had high proportions of HIV virologic control on antiretroviral therapy. PLWH had greater proportions of smoking (P < .001) and comorbid illness than uninfected comparators. There was no difference in COVID-19 severity on admission by HIV status (P = .15). Poor outcomes for hospitalized PLWH were frequent but similar to proportions in comparators; 18% required mechanical ventilation and 21% died during follow-up (compared with 23% and 20%, respectively). There was similar cumulative incidence of death over time by HIV status (P = .94). CONCLUSIONS: We found no differences in adverse outcomes associated with HIV infection for hospitalized COVID-19 patients compared with a demographically similar patient group.

Characterization of Patients Who Return to Hospital Following Discharge from Hospitalization for COVID-19.

BACKGROUND: Data on patients with coronavirus disease 2019 (COVID-19) who return to hospital after discharge are scarce. Characterization of these patients may inform post-hospitalization care. OBJECTIVE: To describe clinical characteristics of patients with COVID-19 who returned to the emergency department (ED) or required readmission within 14 days of discharge. DESIGN: Retrospective cohort study of SARS-COV-2-positive patients with index hospitalization between February 27 and April 12, 2020, with ≥ 14-day follow-up. Significance was defined as P < 0.05 after multiplying P by 125 study-wide comparisons. PARTICIPANTS: Hospitalized patients with confirmed SARS-CoV-2 discharged alive from five New York City hospitals. MAIN MEASURES: Readmission or return to ED following discharge. RESULTS: Of 2864 discharged patients, 103 (3.6%) returned for emergency care after a median of 4.5 days, with 56 requiring inpatient readmission. The most common reason for return was respiratory distress (50%). Compared with patients who did not return, there were higher proportions of COPD (6.8% vs 2.9%) and hypertension (36% vs 22.1%) among those who returned. Patients who returned also had a shorter median length of stay (LOS) during index hospitalization (4.5 [2.9,9.1] vs 6.7 [3.5, 11.5] days; Padjusted = 0.006), and were less likely to have required intensive care on index hospitalization (5.8% vs 19%; Padjusted = 0.001). A trend towards association between absence of in-hospital treatment-dose anticoagulation on index admission and return to hospital was also observed (20.9% vs 30.9%, Padjusted = 0.06). On readmission, rates of intensive care and death were 5.8% and 3.6%, respectively. CONCLUSIONS: Return to hospital after admission for COVID-19 was infrequent within 14 days of discharge. The most common cause for return was respiratory distress. Patients who returned more likely had COPD and hypertension, shorter LOS on index-hospitalization, and lower rates of in-hospital treatment-dose anticoagulation. Future studies should focus on whether these comorbid conditions, longer LOS, and anticoagulation are associated with reduced readmissions.

Machine Learning to Predict Mortality and Critical Events in a Cohort of Patients With COVID-19 in New York City: Model Development and Validation.

BACKGROUND: COVID-19 has infected millions of people worldwide and is responsible for several hundred thousand fatalities. The COVID-19 pandemic has necessitated thoughtful resource allocation and early identification of high-risk patients. However, effective methods to meet these needs are lacking. OBJECTIVE: The aims of this study were to analyze the electronic health records (EHRs) of patients who tested positive for COVID-19 and were admitted to hospitals in the Mount Sinai Health System in New York City; to develop machine learning models for making predictions about the hospital course of the patients over clinically meaningful time horizons based on patient characteristics at admission; and to assess the performance of these models at multiple hospitals and time points. METHODS: We used Extreme Gradient Boosting (XGBoost) and baseline comparator models to predict in-hospital mortality and critical events at time windows of 3, 5, 7, and 10 days from admission. Our study population included harmonized EHR data from five hospitals in New York City for 4098 COVID-19-positive patients admitted from March 15 to May 22, 2020. The models were first trained on patients from a single hospital (n=1514) before or on May 1, externally validated on patients from four other hospitals (n=2201) before or on May 1, and prospectively validated on all patients after May 1 (n=383). Finally, we established model interpretability to identify and rank variables that drive model predictions. RESULTS: Upon cross-validation, the XGBoost classifier outperformed baseline models, with an area under the receiver operating characteristic curve (AUC-ROC) for mortality of 0.89 at 3 days, 0.85 at 5 and 7 days, and 0.84 at 10 days. XGBoost also performed well for critical event prediction, with an AUC-ROC of 0.80 at 3 days, 0.79 at 5 days, 0.80 at 7 days, and 0.81 at 10 days. In external validation, XGBoost achieved an AUC-ROC of 0.88 at 3 days, 0.86 at 5 days, 0.86 at 7 days, and 0.84 at 10 days for mortality prediction. Similarly, the unimputed XGBoost model achieved an AUC-ROC of 0.78 at 3 days, 0.79 at 5 days, 0.80 at 7 days, and 0.81 at 10 days. Trends in performance on prospective validation sets were similar. At 7 days, acute kidney injury on admission, elevated LDH, tachypnea, and hyperglycemia were the strongest drivers of critical event prediction, while higher age, anion gap, and C-reactive protein were the strongest drivers of mortality prediction. CONCLUSIONS: We externally and prospectively trained and validated machine learning models for mortality and critical events for patients with COVID-19 at different time horizons. These models identified at-risk patients and uncovered underlying relationships that predicted outcomes.

Using large language models to assess public perceptions around glucagon-like peptide-1 receptor agonists on social media.

BACKGROUND: The prevalence of obesity has been increasing worldwide, with substantial implications for public health. Obesity is independently associated with cardiovascular morbidity and mortality and is estimated to cost the health system over $200 billion dollars annually. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as a practice-changing therapy for weight loss and cardiovascular risk reduction independent of diabetes. METHODS: We used large language models to augment our previously reported artificial intelligence-enabled topic modeling pipeline to analyze over 390,000 unique GLP-1 RA-related Reddit discussions. RESULTS: We find high interest around GLP-1 RAs, with a total of 168 topics and 33 groups focused on the GLP-1 RA experience with weight loss, comparison of side effects between differing GLP-1 RAs and alternate therapies, issues with GLP-1 RA access and supply, and the positive psychological benefits of GLP-1 RAs and associated weight loss. Notably, public sentiment in these discussions was mostly neutral-to-positive. CONCLUSIONS: These findings have important implications for monitoring new side effects not captured in randomized control trials and understanding the public health challenge of drug shortages.

Obesity is a global public health burden that increases heart disease risk. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a class of medications originally developed for diabetes but are now used to improve lifespans in those with heart disease and increase weight loss. To better understand how the public views this type of drug, over 390,000 discussions from the social media platform Reddit were analyzed using computer software. Topics of discussion included experiences with weight loss, side effects of different GLP-1 RAs, and concerns about drug access and supply. The results showed a mainly neutral-to-positive view of these medications. The findings may help identify new side effects not previously seen in clinical trials and highlight future directions for research and public health efforts.

Contemporary attitudes and beliefs on coronary artery calcium from social media using artificial intelligence.

Coronary artery calcium (CAC) is a powerful tool to refine atherosclerotic cardiovascular disease (ASCVD) risk assessment. Despite its growing interest, contemporary public attitudes around CAC are not well-described in literature and have important implications for shared decision-making around cardiovascular prevention. We used an artificial intelligence (AI) pipeline consisting of a semi-supervised natural language processing model and unsupervised machine learning techniques to analyze 5,606 CAC-related discussions on Reddit. A total of 91 discussion topics were identified and were classified into 14 overarching thematic groups. These included the strong impact of CAC on therapeutic decision-making, ongoing non-evidence-based use of CAC testing, and the patient perceived downsides of CAC testing (e.g., radiation risk). Sentiment analysis also revealed that most discussions had a neutral (49.5%) or negative (48.4%) sentiment. The results of this study demonstrate the potential of an AI-based approach to analyze large, publicly available social media data to generate insights into public perceptions about CAC, which may help guide strategies to improve shared decision-making around ASCVD management and public health interventions.

Novel Domain Knowledge-Encoding Algorithm Enables Label-Efficient Deep Learning for Cardiac CT Segmentation to Guide Atrial Fibrillation Treatment in a Pilot Dataset.

Background: Segmenting computed tomography (CT) is crucial in various clinical applications, such as tailoring personalized cardiac ablation for managing cardiac arrhythmias. Automating segmentation through machine learning (ML) is hindered by the necessity for large, labeled training data, which can be challenging to obtain. This article proposes a novel approach for automated, robust labeling using domain knowledge to achieve high-performance segmentation by ML from a small training set. The approach, the domain knowledge-encoding (DOKEN) algorithm, reduces the reliance on large training datasets by encoding cardiac geometry while automatically labeling the training set. The method was validated in a hold-out dataset of CT results from an atrial fibrillation (AF) ablation study. Methods: The DOKEN algorithm parses left atrial (LA) structures, extracts "anatomical knowledge" by leveraging digital LA models (available publicly), and then applies this knowledge to achieve high ML segmentation performance with a small number of training samples. The DOKEN-labeled training set was used to train a nnU-Net deep neural network (DNN) model for segmenting cardiac CT in N = 20 patients. Subsequently, the method was tested in a hold-out set with N = 100 patients (five times larger than training set) who underwent AF ablation. Results: The DOKEN algorithm integrated with the nn-Unet model achieved high segmentation performance with few training samples, with a training to test ratio of 1:5. The Dice score of the DOKEN-enhanced model was 96.7% (IQR: 95.3% to 97.7%), with a median error in surface distance of boundaries of 1.51 mm (IQR: 0.72 to 3.12) and a mean centroid-boundary distance of 1.16 mm (95% CI: -4.57 to 6.89), similar to expert results (r = 0.99; p < 0.001). In digital hearts, the novel DOKEN approach segmented the LA structures with a mean difference for the centroid-boundary distances of -0.27 mm (95% CI: -3.87 to 3.33; r = 0.99; p < 0.0001). Conclusions: The proposed novel domain knowledge-encoding algorithm was able to perform the segmentation of six substructures of the LA, reducing the need for large training data sets. The combination of domain knowledge encoding and a machine learning approach could reduce the dependence of ML on large training datasets and could potentially be applied to AF ablation procedures and extended in the future to other imaging, 3D printing, and data science applications.

Development and validation of a rapid visual technique for left ventricular hypertrophy detection from the electrocardiogram.

Introduction: Left ventricular hypertrophy (LVH) detection techniques on by electrocardiogram (ECG) are cumbersome to remember with modest performance. This study validated a rapid technique for LVH detection and measured its performance against other techniques. Methods: This was a retrospective cohort study of patients at Stanford Health Care who received ECGs and resting transthoracic echocardiograms (TTE) from 2006 through 2018. The novel technique, Witteles-Somani (WS), assesses for S- and R-wave overlap on adjacent precordial leads. The WS, Sokolow-Lyon, Cornell, and Peguero-Lo Presti techniques were algorithmically implemented on ECGs. Classification metrics, receiver-operator curves, and Pearson correlations measured performance. Age- and sex-adjusted Cox proportional hazard models evaluated associations between incident cardiovascular outcomes and each technique. Results: A total of 53,333 ECG-TTE pairs from 18,873 patients were identified. Of all ECG-TTE pairs, 21,638 (40.6%) had TTE-diagnosed LVH. The WS technique had a sensitivity of 0.46, specificity of 0.66, and AUROC of 0.56, compared to Sokolow-Lyon (AUROC 0.55), Cornell (AUROC 0.63), and Peguero-Lo Presti (AUROC 0.63). Patients meeting LVH by WS technique had a higher risk of cardiovascular mortality [HR 1.18, 95% CI (1.12, 1.24), P < 0.001] and a higher risk of developing any cardiovascular disease [HR 1.29, 95% CI (1.22, 1.36), P < 0.001], myocardial infarction [HR 1.60, 95% CI (1.44, 1.78), P < 0.005], and heart failure [HR 1.24, 95% CI (1.17, 1.32), P < 0.001]. Conclusions: The WS criteria is a rapid visual technique for LVH detection with performance like other LVH detection techniques and is associated with incident cardiovascular outcomes.

Artificial Intelligence-Enabled Analysis of Statin-Related Topics and Sentiments on Social Media.

Importance: Despite compelling evidence that statins are safe, are generally well tolerated, and reduce cardiovascular events, statins are underused even in patients with the highest risk. Social media may provide contemporary insights into public perceptions about statins. Objective: To characterize and classify public perceptions about statins that were gleaned from more than a decade of statin-related discussions on Reddit, a widely used social media platform. Design, Setting, and Participants: This qualitative study analyzed all statin-related discussions on the social media platform that were dated between January 1, 2009, and July 12, 2022. Statin- and cholesterol-focused communities, were identified to create a list of statin-related discussions. An artificial intelligence (AI) pipeline was developed to cluster these discussions into specific topics and overarching thematic groups. The pipeline consisted of a semisupervised natural language processing model (BERT [Bidirectional Encoder Representations from Transformers]), a dimensionality reduction technique, and a clustering algorithm. The sentiment for each discussion was labeled as positive, neutral, or negative using a pretrained BERT model. Exposures: Statin-related posts and comments containing the terms statin and cholesterol. Main Outcomes and Measures: Statin-related topics and thematic groups. Results: A total of 10 233 unique statin-related discussions (961 posts and 9272 comments) from 5188 unique authors were identified. The number of statin-related discussions increased by a mean (SD) of 32.9% (41.1%) per year. A total of 100 discussion topics were identified and were classified into 6 overarching thematic groups: (1) ketogenic diets, diabetes, supplements, and statins; (2) statin adverse effects; (3) statin hesitancy; (4) clinical trial appraisals; (5) pharmaceutical industry bias and statins; and (6) red yeast rice and statins. The sentiment analysis revealed that most discussions had a neutral (66.6%) or negative (30.8%) sentiment. Conclusions and Relevance: Results of this study demonstrated the potential of an AI approach to analyze large, contemporary, publicly available social media data and generate insights into public perceptions about statins. This information may help guide strategies for addressing barriers to statin use and adherence.

Segmenting computed tomograms for cardiac ablation using machine learning leveraged by domain knowledge encoding.

Background: Segmentation of computed tomography (CT) is important for many clinical procedures including personalized cardiac ablation for the management of cardiac arrhythmias. While segmentation can be automated by machine learning (ML), it is limited by the need for large, labeled training data that may be difficult to obtain. We set out to combine ML of cardiac CT with domain knowledge, which reduces the need for large training datasets by encoding cardiac geometry, which we then tested in independent datasets and in a prospective study of atrial fibrillation (AF) ablation. Methods: We mathematically represented atrial anatomy with simple geometric shapes and derived a model to parse cardiac structures in a small set of N = 6 digital hearts. The model, termed "virtual dissection," was used to train ML to segment cardiac CT in N = 20 patients, then tested in independent datasets and in a prospective study. Results: In independent test cohorts (N = 160) from 2 Institutions with different CT scanners, atrial structures were accurately segmented with Dice scores of 96.7% in internal (IQR: 95.3%-97.7%) and 93.5% in external (IQR: 91.9%-94.7%) test data, with good agreement with experts (r = 0.99; p < 0.0001). In a prospective study of 42 patients at ablation, this approach reduced segmentation time by 85% (2.3 ± 0.8 vs. 15.0 ± 6.9 min, p < 0.0001), yet provided similar Dice scores to experts (93.9% (IQR: 93.0%-94.6%) vs. 94.4% (IQR: 92.8%-95.7%), p = NS). Conclusions: Encoding cardiac geometry using mathematical models greatly accelerated training of ML to segment CT, reducing the need for large training sets while retaining accuracy in independent test data. Combining ML with domain knowledge may have broad applications.

Population scale latent space cohort matching for the improved use and exploration of observational trial data.

A significant amount of clinical research is observational by nature and derived from medical records, clinical trials, and large-scale registries. While there is no substitute for randomized, controlled experimentation, such experiments or trials are often costly, time consuming, and even ethically or practically impossible to execute. Combining classical regression and structural equation modeling with matching techniques can leverage the value of observational data. Nevertheless, identifying variables of greatest interest in high-dimensional data is frequently challenging, even with application of classical dimensionality reduction and/or propensity scoring techniques. Here, we demonstrate that projecting high-dimensional medical data onto a lower-dimensional manifold using deep autoencoders and post-hoc generation of treatment/control cohorts based on proximity in the lower-dimensional space results in better matching of confounding variables compared to classical propensity score matching (PSM) in the original high-dimensional space (P<0.0001) and performs similarly to PSM models constructed by experts with prior knowledge of the underlying pathology when evaluated on predicting risk ratios from real-world clinical data. Thus, in cases when the underlying problem is poorly understood and the data is high-dimensional in nature, matching in the autoencoder latent space might be of particular benefit.

Enhancing convolutional neural network predictions of electrocardiograms with left ventricular dysfunction using a novel sub-waveform representation.

Background: Electrocardiogram (ECG) deep learning (DL) has promise to improve the outcomes of patients with cardiovascular abnormalities. In ECG DL, researchers often use convolutional neural networks (CNNs) and traditionally use the full duration of raw ECG waveforms that create redundancies in feature learning and result in inaccurate predictions with large uncertainties. Objective: For enhancing these predictions, we introduced a sub-waveform representation that leverages the rhythmic pattern of ECG waveforms (data-centric approach) rather than changing the CNN architecture (model-centric approach). Results: We applied the proposed representation to a population with 92,446 patients to identify left ventricular dysfunction. We found that the sub-waveform representation increases the performance metrics compared to the full-waveform representation. We observed a 2% increase for area under the receiver operating characteristic curve and 10% increase for area under the precision-recall curve. We also carefully examined three reliability components of explainability, interpretability, and fairness. We provided an explanation for enhancements obtained by heartbeat alignment mechanism. By developing a new scoring system, we interpreted the clinical relevance of ECG features and showed that sub-waveform representation further pushes the scores towards clinical predictions. Finally, we showed that the new representation significantly reduces prediction uncertainties within subgroups that contributes to individual fairness. Conclusion: We expect that this added control over the granularity of ECG data will improve the DL modeling for new artificial intelligence technologies in the cardiovascular space.

Using Deep-Learning Algorithms to Simultaneously Identify Right and Left Ventricular Dysfunction From the Electrocardiogram.

OBJECTIVES: This study sought to develop DL models capable of comprehensively quantifying left and right ventricular dysfunction from ECG data in a large, diverse population. BACKGROUND: Rapid evaluation of left and right ventricular function using deep learning (DL) on electrocardiograms (ECGs) can assist diagnostic workflow. However, DL tools to estimate right ventricular (RV) function do not exist, whereas those to estimate left ventricular (LV) function are restricted to quantification of very low LV function only. METHODS: A multicenter study was conducted with data from 5 New York City hospitals: 4 for internal testing and 1 serving as external validation. We created novel DL models to classify left ventricular ejection fraction (LVEF) into categories derived from the latest universal definition of heart failure, estimate LVEF through regression, and predict a composite outcome of either RV systolic dysfunction or RV dilation. RESULTS: We obtained echocardiogram LVEF estimates for 147,636 patients paired to 715,890 ECGs. We used natural language processing (NLP) to extract RV size and systolic function information from 404,502 echocardiogram reports paired to 761,510 ECGs for 148,227 patients. For LVEF classification in internal testing, area under curve (AUC) at detection of LVEF ≤40%, 40% < LVEF ≤50%, and LVEF >50% was 0.94 (95% CI: 0.94-0.94), 0.82 (95% CI: 0.81-0.83), and 0.89 (95% CI: 0.89-0.89), respectively. For external validation, these results were 0.94 (95% CI: 0.94-0.95), 0.73 (95% CI: 0.72-0.74), and 0.87 (95% CI: 0.87-0.88). For regression, the mean absolute error was 5.84% (95% CI: 5.82%-5.85%) for internal testing and 6.14% (95% CI: 6.13%-6.16%) in external validation. For prediction of the composite RV outcome, AUC was 0.84 (95% CI: 0.84-0.84) in both internal testing and external validation. CONCLUSIONS: DL on ECG data can be used to create inexpensive screening, diagnostic, and predictive tools for both LV and RV dysfunction. Such tools may bridge the applicability of ECGs and echocardiography and enable prioritization of patients for further interventions for either sided failure progressing to biventricular disease.

Development of a machine learning model using electrocardiogram signals to improve acute pulmonary embolism screening.

Aims: Clinical scoring systems for pulmonary embolism (PE) screening have low specificity and contribute to computed tomography pulmonary angiogram (CTPA) overuse. We assessed whether deep learning models using an existing and routinely collected data modality, electrocardiogram (ECG) waveforms, can increase specificity for PE detection. Methods and results: We create a retrospective cohort of 21 183 patients at moderate- to high suspicion of PE and associate 23 793 CTPAs (10.0% PE-positive) with 320 746 ECGs and encounter-level clinical data (demographics, comorbidities, vital signs, and labs). We develop three machine learning models to predict PE likelihood: an ECG model using only ECG waveform data, an EHR model using tabular clinical data, and a Fusion model integrating clinical data and an embedded representation of the ECG waveform. We find that a Fusion model [area under the receiver-operating characteristic curve (AUROC) 0.81 ± 0.01] outperforms both the ECG model (AUROC 0.59 ± 0.01) and EHR model (AUROC 0.65 ± 0.01). On a sample of 100 patients from the test set, the Fusion model also achieves greater specificity (0.18) and performance (AUROC 0.84 ± 0.01) than four commonly evaluated clinical scores: Wells' Criteria, Revised Geneva Score, Pulmonary Embolism Rule-Out Criteria, and 4-Level Pulmonary Embolism Clinical Probability Score (AUROC 0.50-0.58, specificity 0.00-0.05). The model is superior to these scores on feature sensitivity analyses (AUROC 0.66-0.84) and achieves comparable performance across sex (AUROC 0.81) and racial/ethnic (AUROC 0.77-0.84) subgroups. Conclusion: Synergistic deep learning of ECG waveforms with traditional clinical variables can increase the specificity of PE detection in patients at least at moderate suspicion for PE.

Health Equity in Artificial Intelligence and Primary Care Research: Protocol for a Scoping Review.

BACKGROUND: Though artificial intelligence (AI) has the potential to augment the patient-physician relationship in primary care, bias in intelligent health care systems has the potential to differentially impact vulnerable patient populations. OBJECTIVE: The purpose of this scoping review is to summarize the extent to which AI systems in primary care examine the inherent bias toward or against vulnerable populations and appraise how these systems have mitigated the impact of such biases during their development. METHODS: We will conduct a search update from an existing scoping review to identify studies on AI and primary care in the following databases: Medline-OVID, Embase, CINAHL, Cochrane Library, Web of Science, Scopus, IEEE Xplore, ACM Digital Library, MathSciNet, AAAI, and arXiv. Two screeners will independently review all abstracts, titles, and full-text articles. The team will extract data using a structured data extraction form and synthesize the results in accordance with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. RESULTS: This review will provide an assessment of the current state of health care equity within AI for primary care. Specifically, we will identify the degree to which vulnerable patients have been included, assess how bias is interpreted and documented, and understand the extent to which harmful biases are addressed. As of October 2020, the scoping review is in the title- and abstract-screening stage. The results are expected to be submitted for publication in fall 2021. CONCLUSIONS: AI applications in primary care are becoming an increasingly common tool in health care delivery and in preventative care efforts for underserved populations. This scoping review would potentially show the extent to which studies on AI in primary care employ a health equity lens and take steps to mitigate bias. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/27799.