Heart failure risk stratification using artificial intelligence applied to electrocardiogram images: a multinational study

Abstract Background and Aims Current heart failure (HF) risk stratification strategies require comprehensive clinical evaluation. In this study, artificial intelligence (AI) applied to electrocardiogram (ECG) images was examined as a strategy to predict HF risk. Methods Across multinational cohorts in the Yale New Haven Health System (YNHHS), UK Biobank (UKB), and Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), individuals without baseline HF were followed for the first HF hospitalization. An AI-ECG model that defines cross-sectional left ventricular systolic dysfunction from 12-lead ECG images was used, and its association with incident HF was evaluated. Discrimination was assessed using Harrell’s C-statistic. Pooled cohort equations to prevent HF (PCP-HF) were used as a comparator. Results Among 231 285 YNHHS patients, 4472 had primary HF hospitalizations over 4.5 years (inter-quartile range 2.5–6.6). In UKB and ELSA-Brasil, among 42 141 and 13 454 people, 46 and 31 developed HF over 3.1 (2.1–4.5) and 4.2 (3.7–4.5) years. A positive AI-ECG screen portended a 4- to 24-fold higher risk of new-onset HF [age-, sex-adjusted hazard ratio: YNHHS, 3.88 (95% confidence interval 3.63–4.14); UKB, 12.85 (6.87–24.02); ELSA-Brasil, 23.50 (11.09–49.81)]. The association was consistent after accounting for comorbidities and the competing risk of death. Higher probabilities were associated with progressively higher HF risk. Model discrimination was 0.718 in YNHHS, 0.769 in UKB, and 0.810 in ELSA-Brasil. In YNHHS and ELSA-Brasil, incorporating AI-ECG with PCP-HF yielded a significant improvement in discrimination over PCP-HF alone. Conclusions An AI model applied to a single ECG image defined the risk of future HF, representing a digital biomarker for stratifying HF risk.