Risk stratification of chest pain in the emergency department using artificial intelligence applied to electrocardiograms

BACKGROUND: Despite standardised approaches, subjective assessment and inconsistent diagnostic testing for chest pain in the emergency department (ED) drive costs, disparities and adverse outcomes. Artificial intelligence offers potential to automate and improve risk stratification. METHODS AND RESULTS: Using a retrospective cohort of 15 048 patients presenting to the ED of a tertiary care hospital, we trained a neural network classifier ('Chest Pain-AI' or 'CP-AI') to predict a 7-day composite endpoint of major cardiovascular diagnoses including myocardial infarction, pulmonary embolism, aortic dissection and all-cause mortality. Inputs to CP-AI included age, sex, cardiac biomarkers (D-dimer or troponin I or T positivity) and numerical representations of presenting 12-lead ECGs. ECG representations were derived using a publicly available deep learning model known as patient contrastive learning of representations. In an external validation set of 14 476 patients, we evaluated CP-AI against comparator models, including a 'Biomarker Model' incorporating clinical data (age, sex, biomarker positivity), based on both the area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve (AUPRC). CP-AI outperformed the Biomarker Model in prediction of the 7-day composite endpoint with an AUROC of 0.82 (95% CI 0.81 to 0.83) vs 0.79 (95% CI 0.78 to 0.81) and an AUPRC of 0.46 (95% CI 0.44 to 0.49) vs 0.35 (95% CI 0.33 to 0.37) (p<0.05 for both comparisons). CONCLUSIONS: CP-AI, a fully automated neural network classifier, demonstrated superior performance in the prediction of 7-day major cardiovascular diagnoses for patients presenting with acute chest pain compared with conventional models trained on demographics and cardiac biomarkers. CP-AI may standardise and expedite risk stratification of patients presenting to the ED with chest pain.