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Michel L, Jehn S, Dykun I, Anker MS, Ferdinandy P, Dobrev D, Rassaf T, Mahabadi AA, Totzeck M. Detectable troponin below the 99 th percentile predicts survival in patients undergoing coronary angiography. IJC HEART & VASCULATURE 2024; 52:101419. [PMID: 38725439 PMCID: PMC11079461 DOI: 10.1016/j.ijcha.2024.101419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024]
Abstract
Background Cardiac troponin I (cTnI) above the 99th percentile is associated with an increased risk of major adverse events. Patients with detectable cTnI below the 99th percentile are a heterogeneous group with a less well-defined risk profile. The purpose of this study is to investigate the prognostic relevance of detectable cTnI below the 99th percentile in patients undergoing coronary angiography. Methods The study included 14,776 consecutive patients (mean age of 65.4 ± 12.7 years, 71.3 % male) from the Essen Coronary Artery Disease (ECAD) registry. Patients with cTnI levels above the 99th percentile and patients with ST-segment elevation acute myocardial infarction were excluded. All-cause mortality was defined as the primary endpoint. Results Detectable cTnI below the 99th percentile was present in 2811 (19.0 %) patients, while 11,965 (81.0 %) patients were below detection limit of the employed assay. The mean follow-up was 4.25 ± 3.76 years. All-cause mortality was 20.8 % for patients with detectable cTnI below the 99th percentile and 15.0 % for those without detectable cTnI. In a multivariable Cox regression analysis, detectable cTnI was independently associated with all-cause mortality with a hazard ratio of 1.60 (95 % CI 1.45-1.76; p < 0.001). There was a stepwise relationship with increasing all-cause mortality and tertiles of detectable cTnI levels with hazard ratios of 1.63 (95 % CI 1.39-1.90) for the first tertile to 2.02 (95 % CI 1.74-2.35) for the third tertile. Conclusions Detectable cTnI below the 99th percentile is an independent predictor of mortality in patients undergoing coronary angiography with the risk of death growing progressively with increasing troponin levels.
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Affiliation(s)
- Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Stefanie Jehn
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Iryna Dykun
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Markus S. Anker
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
- Berlin Institute of Health (BIH) at Charité Berlin, Universitätsmedizin Berlin, Germany
- Deutsches Herzzentrum der Charité CBF, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Hospital Essen, Germany
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montréal, QC, Canada
- Department of Integrative Physiology, Baylor College of Medicine, Houston, TX, USA
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Amir A. Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Germany
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Guan L, Wang CH, Sun H, Sun ZJ. Development and validation of a nomogram model for all-cause mortality risk in patients with chronic heart failure and atrial fibrillation. BMC Geriatr 2024; 24:470. [PMID: 38811919 PMCID: PMC11138095 DOI: 10.1186/s12877-024-05059-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 05/08/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND As the global aging process continues to accelerate, heart failure (HF) has become an important cause of increased morbidity and mortality in elderly patients. Chronic atrial fibrillation (AF) is a major risk factor for HF. Patients with HF combined with AF are more difficult to treat and have a worse prognosis. The aim of this study was to explore the risk factors for 1-year mortality in patients with HF combined with AF and to develop a risk prediction assessment model. METHODS We recruited hospitalized patients with HF and AF who received standardized care in the Department of Cardiology at Shengjing Hospital of China Medical University from January 2013 to December 2018. The patients were randomly divided into modeling and internal validation groups using a random number generator at a 1:1 ratio. Multivariate Cox regression analysis was used to identify risk factors for all-cause mortality during a one-year follow-up period. Then, a nomogram was constructed based on the weights of each index and validated. Receiver operating characteristic curve, the area under the curve (AUC), decision curve, and calibration curve analyses for survival were used to evaluate the model's predictive and clinical validities and calibration. RESULTS We included 3,406 patients who met the eligibility criteria; 1,703 cases each were included in the modeling and internal validation groups. Eight statistically significant predictors were identified: age, sex, New York Heart Association cardiac function class III or IV, a history of myocardial infarction, and the albumin, triglycerides, N-terminal pro-b-type natriuretic peptide, and blood urea nitrogen levels. The AUCs were 0.793 (95% confidence interval: 0.763-0.823) and 0.794 (95% confidence interval: 0.763-0.823) in the modeling and validation cohorts, respectively. CONCLUSIONS We present a predictive model for all-cause mortality in patients with coexisting HF and AF comprising eight key factors. This model gives clinicians a simple assessment tool that may improve the clinical management of these patients.
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Affiliation(s)
- Lin Guan
- Department of Cardiology, Shengjing Hospital of China Medical University, 39 Huaxiang Road, Tiexi Zone, Shenyang, 110022, China
| | - Chuan-He Wang
- Department of Cardiology, Shengjing Hospital of China Medical University, 39 Huaxiang Road, Tiexi Zone, Shenyang, 110022, China
| | - Hao Sun
- Department of Clinical Epidemiology and Evidence-Based Medicine, the First Hospital of China Medical University, Shenyang, 110001, China.
| | - Zhi-Jun Sun
- Department of Cardiology, Shengjing Hospital of China Medical University, 39 Huaxiang Road, Tiexi Zone, Shenyang, 110022, China.
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Xie P, Wang H, Xiao J, Xu F, Liu J, Chen Z, Zhao W, Hou S, Wu D, Ma Y, Xiao J. Development and Validation of an Explainable Deep Learning Model to Predict In-Hospital Mortality for Patients With Acute Myocardial Infarction: Algorithm Development and Validation Study. J Med Internet Res 2024; 26:e49848. [PMID: 38728685 PMCID: PMC11127140 DOI: 10.2196/49848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/02/2023] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) is one of the most severe cardiovascular diseases and is associated with a high risk of in-hospital mortality. However, the current deep learning models for in-hospital mortality prediction lack interpretability. OBJECTIVE This study aims to establish an explainable deep learning model to provide individualized in-hospital mortality prediction and risk factor assessment for patients with AMI. METHODS In this retrospective multicenter study, we used data for consecutive patients hospitalized with AMI from the Chongqing University Central Hospital between July 2016 and December 2022 and the Electronic Intensive Care Unit Collaborative Research Database. These patients were randomly divided into training (7668/10,955, 70%) and internal test (3287/10,955, 30%) data sets. In addition, data of patients with AMI from the Medical Information Mart for Intensive Care database were used for external validation. Deep learning models were used to predict in-hospital mortality in patients with AMI, and they were compared with linear and tree-based models. The Shapley Additive Explanations method was used to explain the model with the highest area under the receiver operating characteristic curve in both the internal test and external validation data sets to quantify and visualize the features that drive predictions. RESULTS A total of 10,955 patients with AMI who were admitted to Chongqing University Central Hospital or included in the Electronic Intensive Care Unit Collaborative Research Database were randomly divided into a training data set of 7668 (70%) patients and an internal test data set of 3287 (30%) patients. A total of 9355 patients from the Medical Information Mart for Intensive Care database were included for independent external validation. In-hospital mortality occurred in 8.74% (670/7668), 8.73% (287/3287), and 9.12% (853/9355) of the patients in the training, internal test, and external validation cohorts, respectively. The Self-Attention and Intersample Attention Transformer model performed best in both the internal test data set and the external validation data set among the 9 prediction models, with the highest area under the receiver operating characteristic curve of 0.86 (95% CI 0.84-0.88) and 0.85 (95% CI 0.84-0.87), respectively. Older age, high heart rate, and low body temperature were the 3 most important predictors of increased mortality, according to the explanations of the Self-Attention and Intersample Attention Transformer model. CONCLUSIONS The explainable deep learning model that we developed could provide estimates of mortality and visual contribution of the features to the prediction for a patient with AMI. The explanations suggested that older age, unstable vital signs, and metabolic disorders may increase the risk of mortality in patients with AMI.
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Affiliation(s)
- Puguang Xie
- Chongqing Emergency Medical Centre, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Hao Wang
- Chongqing Emergency Medical Centre, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Jun Xiao
- Chongqing Emergency Medical Centre, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Fan Xu
- Chongqing Emergency Medical Centre, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Jingyang Liu
- Chongqing Emergency Medical Centre, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Zihang Chen
- Bioengineering College, Chongqing University, Chongqing, China
| | - Weijie Zhao
- Bioengineering College, Chongqing University, Chongqing, China
| | - Siyu Hou
- Bio-Med Informatics Research Centre & Clinical Research Centre, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Dongdong Wu
- Medical Big Data Research Centre, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yu Ma
- Chongqing Emergency Medical Centre, Chongqing University Central Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Jingjing Xiao
- Bio-Med Informatics Research Centre & Clinical Research Centre, Xinqiao Hospital, Army Medical University, Chongqing, China
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Lopes J, Faria M, Santos MF. Exploring trends and autonomy levels of adaptive business intelligence in healthcare: A systematic review. PLoS One 2024; 19:e0302697. [PMID: 38728308 PMCID: PMC11086907 DOI: 10.1371/journal.pone.0302697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE In order to comprehensively understand the characteristics of Adaptive Business Intelligence (ABI) in Healthcare, this study is structured to provide insights into the common features and evolving patterns within this domain. Applying the Sheridan's Classification as a framework, we aim to assess the degree of autonomy exhibited by various ABI components. Together, these objectives will contribute to a deeper understanding of ABI implementation and its implications within the Healthcare context. METHODS A comprehensive search of academic databases was conducted to identify relevant studies, selecting AIS e-library (AISel), Decision Support Systems Journal (DSSJ), Nature, The Lancet Digital Health (TLDH), PubMed, Expert Systems with Application (ESWA) and npj Digital Medicine as information sources. Studies from 2006 to 2022 were included based on predefined eligibility criteria. PRISMA statements were used to report this study. RESULTS The outcomes showed that ABI systems present distinct levels of development, autonomy and practical deployment. The high levels of autonomy were essentially associated with predictive components. However, the possibility of completely autonomous decisions by these systems is totally excluded. Lower levels of autonomy are also observed, particularly in connection with prescriptive components, granting users responsibility in the generation of decisions. CONCLUSION The study presented emphasizes the vital connection between desired outcomes and the inherent autonomy of these solutions, highlighting the critical need for additional research on the consequences of ABI systems and their constituent elements. Organizations should deploy these systems in a way consistent with their objectives and values, while also being mindful of potential adverse effects. Providing valuable insights for researchers, practitioners, and policymakers aiming to comprehend the diverse levels of ABI systems implementation, it contributes to well-informed decision-making in this dynamic field.
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Affiliation(s)
- João Lopes
- ALGORITMI Research Center, University of Minho, Braga, Portugal
| | - Mariana Faria
- ALGORITMI Research Center, University of Minho, Braga, Portugal
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D'Ascenzo F, Fabris E, DeGregorio C, Mittone G, De Filippo O, Wańha W, Leonardi S, Roubin SR, Chinaglia A, Truffa A, Huczek Z, Gaibazzi N, Ielasi A, Cortese B, Borin A, Pagliaro B, Núñez-Gil IJ, Ugo F, Marengo G, Barbieri L, Marchini F, Desperak P, Melendo-Viu M, Montalto C, Bianco M, Bruno F, Mancone M, Ferrandez-Escarabajal M, Morici N, Scaglione M, Tuttolomondo D, Gąsior M, Mazurek M, Gallone G, Campo G, Wojakowski W, Abu Assi E, Stefanini G, Sinagra G, de Ferrari GM. Forecasting the Risk of Heart Failure Hospitalization After Acute Coronary Syndromes: the CORALYS HF Score. Am J Cardiol 2023; 206:320-329. [PMID: 37734293 DOI: 10.1016/j.amjcard.2023.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 09/23/2023]
Abstract
The present study aimed to identify patients at a higher risk of hospitalization for heart failure (HF) in a population of patients with acute coronary syndrome (ACS) treated with percutaneous coronary revascularization without a history of HF or reduced left ventricular (LV) ejection fraction before the index admission. We performed a Cox regression multivariable analysis with competitive risk and machine learning models on the incideNce and predictOrs of heaRt fAiLure After Acute coronarY Syndrome (CORALYS) registry (NCT04895176), an international and multicenter study including consecutive patients admitted for ACS in 16 European Centers from 2015 to 2020. Of 14,699 patients, 593 (4.0%) were admitted for the development of HF up to 1 year after the index ACS presentation. A total of 2 different data sets were randomly created, 1 for the derivative cohort including 11,626 patients (80%) and 1 for the validation cohort including 3,073 patients (20%). On the Cox regression multivariable analysis, several variables were associated with the risk of HF hospitalization, with reduced renal function, complete revascularization, and LV ejection fraction as the most relevant ones. The area under the curve at 1 year was 0.75 (0.72 to 0.78) in the derivative cohort, whereas on validation, it was 0.72 (0.67 to 0.77). The machine learning analysis showed a slightly inferior performance. In conclusion, in a large cohort of patients with ACS without a history of HF or LV dysfunction before the index event, the CORALYS HF score identified patients at a higher risk of hospitalization for HF using variables easily accessible at discharge. Further approaches to tackle HF development in this high-risk subset of patients are needed.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy.
| | - Enrico Fabris
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Caterina DeGregorio
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Gianluca Mittone
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Alessandra Chinaglia
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | | | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, Parma, Italy
| | - Alfonso Ielasi
- U.O. di Cardiologia Clinica ed Interventistica, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Bernardo Cortese
- Cardiovascular Research Team, San Carlo Clinic, Milano, Italy; Fondazione Ricerca e Innovazione Cardiovascolare, Milano, Italy
| | - Andrea Borin
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | | | - Iván J Núñez-Gil
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
| | - Fabrizio Ugo
- Division of Cardiology, Ospedale Sant'Andrea di Vercelli, Vercelli, Italy
| | - Giorgio Marengo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy; Departement of Informatica, University of Turin, Turin, Italy
| | - Lucia Barbieri
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy; Division of Cardiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; University of Milan, Milan, Italy
| | - Federico Marchini
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Piotr Desperak
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Claudio Montalto
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Matteo Bianco
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | - Massimo Mancone
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Nuccia Morici
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Scaglione
- Division of Cardiology, Ospedale Cardinal G. Massaia, Asti, Italy
| | | | - Mariusz Gąsior
- Departement of Informatica, University of Turin, Turin, Italy
| | - Maciej Mazurek
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | | | - Emad Abu Assi
- Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Gaetano Maria de Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
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Li X, Yu X, Tian D, Liu Y, Li D. Exploring and validating the prognostic value of pathomics signatures and genomics in patients with cutaneous melanoma based on bioinformatics and deep learning. Med Phys 2023; 50:7049-7059. [PMID: 37722701 DOI: 10.1002/mp.16748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 08/17/2023] [Accepted: 09/08/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Cutaneous melanoma (CM) is the most common malignant tumor of the skin. Our study aimed to investigate the prognostic value of pathomics signatures for CM by combining pathomics and genomics. PURPOSE The purpose of this study was to explore the potential application value of pathomics signatures. METHODS Pathology full scans, clinical information, and genomics data for CM patients were downloaded from The Cancer Genome Atlas (TCGA) database. Exploratory data analysis (EDA) was used to visualize patient characteristics. Genes related to a poorer prognosis were screened through differential analysis. Survival analysis was performed to assess the prognostic value of gene and pathomics signatures. Artificial neural network (ANN) models predicted prognosis using signatures and genes. Correlation analysis was used to explore signature-gene links. RESULTS The clinical traits for 468 CM samples and the genomic data and pathology images for 471 CM samples were obtained from the TCGA database. The EDA results combined with multiple machine learning (ML) models suggested that the top 5 clinical traits in terms of importance were age, biopsy site, T stage, N stage and overall disease stage, and the eight ML models had a precision lower than 0.56. A total of 60 differentially expressed genes were obtained by comparing sequencing data. A total of 413 available quantitative signatures of each pathomics image were obtained with CellProfile software. The precision of the binary classification model based on pathomics signatures was 0.99, with a loss value of 1.7119e-04. The precision of the binary classification model based on differentially expressed genes was 0.98, with a loss value of 0.1101. The precision of the binary classification model based on pathomics signatures and differentially expressed genes was 0.97, with a loss value of 0.2088. The survival analyses showed that the survival rate of the high-risk group based on gene expression and pathomics signatures was significantly lower than that of the low-risk group. A total of 222 pathomics signatures and 51 differentially expressed genes were analyzed for survival with p-values of less than 0.05. There was a certain correlation between some pathomics signatures and differential gene expression involving ANO2, LINC00158, NDNF, ADAMTS15, and ADGRB3, etc. CONCLUSION: This study evaluated the prognostic significance of pathomics signatures and differentially expressed genes in CM patients. Three ANN models were developed, and all achieved accuracy rates higher than 97%. Specifically, the pathomics signature-based ANN model maintained a remarkable accuracy of 99%. These findings highlight the CellProfile + ANN model as an excellent choice for prognostic prediction in CM patients. Furthermore, our correlation analysis experimentally demonstrated a preliminary link between disease quantification and qualitative changes. Among various features, including M stage and treatments received, special attention should be given to age, biopsy site, T stage, N stage, and overall disease stage in CM patients.
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Affiliation(s)
- Xiaoyuan Li
- Department of Traditional Chinese Medicine, The affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xiaoqian Yu
- Department of Dermatology, Qingdao Hiser Hospital Affiliated of Qingdao University (Qingdao Traditional Chinese Medicine Hospital), Qingdao, Shandong, China
| | - Duanliang Tian
- Department of Tuina, Qingdao Hiser Hospital Affiliated of Qingdao University (Qingdao Traditional Chinese Medicine Hospital), Qingdao, Shandong, China
| | - Yiran Liu
- Department of Traditional Chinese Medicine, Weifang Medical College, Weifang, Shandong, China
| | - Ding Li
- Department of Traditional Chinese Medicine, The affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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Kharrat A, Zhu F, Baczynski M, Ye XY, Weisz D, Jain A. Organ dysfunction and mortality in preterm neonates with late-onset bloodstream infection. Pediatr Res 2023; 94:1044-1050. [PMID: 36906720 DOI: 10.1038/s41390-023-02541-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Organ dysfunction (ODF) in late-onset bloodstream infection (LBSI) is associated with increased risk of adverse outcomes. However, no established definition of ODF exists among preterm neonates. Our objective was to describe an outcome-based ODF definition for preterm infants, and assess factors associated with mortality. METHODS This is a six-year retrospective study of neonates <35 weeks gestational age, >72 h of age, with non-CONS bacterial/fungal LBSI. Discriminatory ability of each parameter for mortality was evaluated: base deficit ≤-8 mmol/L (BD8), renal dysfunction (urine output <1 cc/kg/h or creatinine ≥100 μmol/L), hypoxic respiratory failure (HRF, ventilated, FiO2 = 1.0), or vasopressor/inotrope use (V/I). Multivariable logistic regression analysis was performed to derive a mortality score. RESULTS One hundred and forty-eight infants had LBSI. BD8 had the highest individual predictive ability for mortality (AUROC = 0.78). The combination BD8 + HRF + V/I was used to define ODF (AUROC = 0.84). Fifty-seven (39%) infants developed ODF, among which 28 (49%) died. Mortality increased inversely relative to GA at LBSI-onset (aOR 0.81 [0.67, 0.98]) and directly relative to ODF occurrence (12.15 [4.48, 33.92]). Compared to no-ODF, ODF infants had lower GA and age at illness, and higher frequency of Gram-negative pathogen. CONCLUSIONS Among preterm neonates with LBSI, significant metabolic acidosis, HRF, and vasopressor/inotrope use may identify infants high risk for mortality. These criteria could help identify patients for future studies of adjunctive therapies. IMPACT Sepsis-related organ dysfunction is associated with increased risk of adverse outcomes. Among preterm neonates, significant metabolic acidosis, use of vasopressors/inotropes, and hypoxic respiratory failure may identify high-risk infants. This can be used to target research and quality improvement efforts toward the most vulnerable infants.
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Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.
| | - Faith Zhu
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Xiang Y Ye
- MiCare Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Dany Weisz
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
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Li X, Shang C, Xu C, Wang Y, Xu J, Zhou Q. Development and comparison of machine learning-based models for predicting heart failure after acute myocardial infarction. BMC Med Inform Decis Mak 2023; 23:165. [PMID: 37620904 PMCID: PMC10463624 DOI: 10.1186/s12911-023-02240-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 07/13/2023] [Indexed: 08/26/2023] Open
Abstract
AIMS Heart failure (HF) is one of the common adverse cardiovascular events after acute myocardial infarction (AMI), but the predictive efficacy of numerous machine learning (ML) built models is unclear. This study aimed to build an optimal model to predict the occurrence of HF in AMI patients by comparing seven ML algorithms. METHODS Cohort 1 included AMI patients from 2018 to 2019 divided into HF and control groups. All first routine test data of the study subjects were collected as the features to be selected for the model, and seven ML algorithms with screenable features were evaluated. Cohort 2 contains AMI patients from 2020 to 2021 to establish an early warning model with external validation. ROC curve and DCA curve to analyze the diagnostic efficacy and clinical benefit of the model respectively. RESULTS The best performer among the seven ML algorithms was XgBoost, and the features of XgBoost algorithm for troponin I, triglycerides, urine red blood cell count, γ-glutamyl transpeptidase, glucose, urine specific gravity, prothrombin time, prealbumin, and urea were ranked high in importance. The AUC of the HF-Lab9 prediction model built by the XgBoost algorithm was 0.966 and had good clinical benefits. CONCLUSIONS This study screened the optimal ML algorithm as XgBoost and developed the model HF-Lab9 will improve the accuracy of clinicians in assessing the occurrence of HF after AMI and provide a reference for the selection of subsequent model-building algorithms.
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Affiliation(s)
- Xuewen Li
- Department of Laboratory Medicine, First Hospital of Jilin University, Changchun, China
| | - Chengming Shang
- Information center, First Hospital of Jilin University, Changchun, China
| | - Changyan Xu
- Medical Department, First Hospital of Jilin University, Changchun, China
| | - Yiting Wang
- Department of Laboratory Medicine, First Hospital of Jilin University, Changchun, China
| | - Jiancheng Xu
- Department of Laboratory Medicine, First Hospital of Jilin University, Changchun, China
| | - Qi Zhou
- Department of Pediatrics, First Hospital of Jilin University, 1Xinmin Street, Changchun, 130021, Jilin, China.
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9
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Ledziński Ł, Grześk G. Artificial Intelligence Technologies in Cardiology. J Cardiovasc Dev Dis 2023; 10:jcdd10050202. [PMID: 37233169 DOI: 10.3390/jcdd10050202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/27/2023] Open
Abstract
As the world produces exabytes of data, there is a growing need to find new methods that are more suitable for dealing with complex datasets. Artificial intelligence (AI) has significant potential to impact the healthcare industry, which is already on the road to change with the digital transformation of vast quantities of information. The implementation of AI has already achieved success in the domains of molecular chemistry and drug discoveries. The reduction in costs and in the time needed for experiments to predict the pharmacological activities of new molecules is a milestone in science. These successful applications of AI algorithms provide hope for a revolution in healthcare systems. A significant part of artificial intelligence is machine learning (ML), of which there are three main types-supervised learning, unsupervised learning, and reinforcement learning. In this review, the full scope of the AI workflow is presented, with explanations of the most-often-used ML algorithms and descriptions of performance metrics for both regression and classification. A brief introduction to explainable artificial intelligence (XAI) is provided, with examples of technologies that have developed for XAI. We review important AI implementations in cardiology for supervised, unsupervised, and reinforcement learning and natural language processing, emphasizing the used algorithm. Finally, we discuss the need to establish legal, ethical, and methodical requirements for the deployment of AI models in medicine.
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Affiliation(s)
- Łukasz Ledziński
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75, 85-168 Bydgoszcz, Poland
| | - Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75, 85-168 Bydgoszcz, Poland
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10
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Kresoja KP, Unterhuber M, Wachter R, Thiele H, Lurz P. A cardiologist's guide to machine learning in cardiovascular disease prognosis prediction. Basic Res Cardiol 2023; 118:10. [PMID: 36939941 PMCID: PMC10027799 DOI: 10.1007/s00395-023-00982-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/21/2023]
Abstract
A modern-day physician is faced with a vast abundance of clinical and scientific data, by far surpassing the capabilities of the human mind. Until the last decade, advances in data availability have not been accompanied by analytical approaches. The advent of machine learning (ML) algorithms might improve the interpretation of complex data and should help to translate the near endless amount of data into clinical decision-making. ML has become part of our everyday practice and might even further change modern-day medicine. It is important to acknowledge the role of ML in prognosis prediction of cardiovascular disease. The present review aims on preparing the modern physician and researcher for the challenges that ML might bring, explaining basic concepts but also caveats that might arise when using these methods. Further, a brief overview of current established classical and emerging concepts of ML disease prediction in the fields of omics, imaging and basic science is presented.
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Affiliation(s)
- Karl-Patrik Kresoja
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstr. 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig Heart Science at Heart Center Leipzig, Leipzig, Germany
| | - Matthias Unterhuber
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstr. 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig Heart Science at Heart Center Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
- German Cardiovascular Research Center (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstr. 39, 04289, Leipzig, Germany.
- Leipzig Heart Institute, Leipzig Heart Science at Heart Center Leipzig, Leipzig, Germany.
| | - Philipp Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstr. 39, 04289, Leipzig, Germany.
- Leipzig Heart Institute, Leipzig Heart Science at Heart Center Leipzig, Leipzig, Germany.
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11
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Rylance RT, Wagner P, Olesen KKW, Carlson J, Alfredsson J, Jernberg T, Leosdottir M, Johansson P, Vasko P, Maeng M, Mohammed MA, Erlinge D. Patient-oriented risk score for predicting death 1 year after myocardial infarction: the SweDen risk score. Open Heart 2022; 9:openhrt-2022-002143. [PMID: 36460308 PMCID: PMC9723953 DOI: 10.1136/openhrt-2022-002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Our aim was to derive, based on the SWEDEHEART registry, and validate, using the Western Denmark Heart registry, a patient-oriented risk score, the SweDen score, which could calculate the risk of 1-year mortality following a myocardial infarction (MI). METHODS The factors included in the SweDen score were age, sex, smoking, diabetes, heart failure and statin use. These were chosen a priori by the SWEDEHEART steering group based on the premise that the factors were information known by the patients themselves. The score was evaluated using various statistical methods such as time-dependent receiver operating characteristics curves of the linear predictor, area under the curve metrics, Kaplan-Meier survivor curves and the calibration slope. RESULTS The area under the curve values were 0.81 in the derivation data and 0.76 in the validation data. The Kaplan-Meier curves showed similar patient profiles across datasets. The calibration slope was 1.03 (95% CI 0.99 to 1.08) in the validation data using the linear predictor from the derivation data. CONCLUSIONS The SweDen risk score is a novel tool created for patient use. The risk score calculator will be available online and presents mortality risk on a colour scale to simplify interpretation and to avoid exact life span expectancies. It provides a validated patient-oriented risk score predicting the risk of death within 1 year after suffering an MI, which visualises the benefit of statin use and smoking cessation in a simple way.
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Affiliation(s)
- Rebecca Tremain Rylance
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Philippe Wagner
- Center for Clinical Research, Uppsala University, Uppsala, Sweden
| | - Kevin K W Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Karolinska University Hospital, Linkoping, Sweden
| | - Tomas Jernberg
- The Swedish Heart and Lung Association, Stockholm, Sweden
| | - Margret Leosdottir
- Department of Clinical Sciences, Skåne University Hospital Lund, Malmö, Sweden,Department of Clinical Sciences, Lund University, Malmo, Sweden
| | | | - Peter Vasko
- Department of Cardiology, Karolinska University Hospital, Linkoping, Sweden
| | - Michael Maeng
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Moman Aladdin Mohammed
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
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12
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Huang JD, Wang J, Ramsey E, Leavey G, Chico TJA, Condell J. Applying Artificial Intelligence to Wearable Sensor Data to Diagnose and Predict Cardiovascular Disease: A Review. SENSORS (BASEL, SWITZERLAND) 2022; 22:8002. [PMID: 36298352 PMCID: PMC9610988 DOI: 10.3390/s22208002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/06/2022] [Accepted: 10/13/2022] [Indexed: 06/06/2023]
Abstract
Cardiovascular disease (CVD) is the world's leading cause of mortality. There is significant interest in using Artificial Intelligence (AI) to analyse data from novel sensors such as wearables to provide an earlier and more accurate prediction and diagnosis of heart disease. Digital health technologies that fuse AI and sensing devices may help disease prevention and reduce the substantial morbidity and mortality caused by CVD worldwide. In this review, we identify and describe recent developments in the application of digital health for CVD, focusing on AI approaches for CVD detection, diagnosis, and prediction through AI models driven by data collected from wearables. We summarise the literature on the use of wearables and AI in cardiovascular disease diagnosis, followed by a detailed description of the dominant AI approaches applied for modelling and prediction using data acquired from sensors such as wearables. We discuss the AI algorithms and models and clinical applications and find that AI and machine-learning-based approaches are superior to traditional or conventional statistical methods for predicting cardiovascular events. However, further studies evaluating the applicability of such algorithms in the real world are needed. In addition, improvements in wearable device data accuracy and better management of their application are required. Lastly, we discuss the challenges that the introduction of such technologies into routine healthcare may face.
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Affiliation(s)
- Jian-Dong Huang
- School of Computing, Engineering and Intelligent Systems, Ulster University at Magee, Londonderry BT48 7JL, UK
| | - Jinling Wang
- School of Computing, Engineering and Intelligent Systems, Ulster University at Magee, Londonderry BT48 7JL, UK
| | - Elaine Ramsey
- Department of Global Business & Enterprise, Ulster University at Magee, Londonderry BT48 7JL, UK
| | - Gerard Leavey
- School of Psychology, Ulster University at Coleraine, Londonderry BT52 1SA, UK
| | - Timothy J. A. Chico
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School, The University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK
| | - Joan Condell
- School of Computing, Engineering and Intelligent Systems, Ulster University at Magee, Londonderry BT48 7JL, UK
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13
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Błaziak M, Urban S, Wietrzyk W, Jura M, Iwanek G, Stańczykiewicz B, Kuliczkowski W, Zymliński R, Pondel M, Berka P, Danel D, Biegus J, Siennicka A. An Artificial Intelligence Approach to Guiding the Management of Heart Failure Patients Using Predictive Models: A Systematic Review. Biomedicines 2022; 10:biomedicines10092188. [PMID: 36140289 PMCID: PMC9496386 DOI: 10.3390/biomedicines10092188] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/19/2022] [Accepted: 08/27/2022] [Indexed: 11/23/2022] Open
Abstract
Heart failure (HF) is one of the leading causes of mortality and hospitalization worldwide. The accurate prediction of mortality and readmission risk provides crucial information for guiding decision making. Unfortunately, traditional predictive models reached modest accuracy in HF populations. We therefore aimed to present predictive models based on machine learning (ML) techniques in HF patients that were externally validated. We searched four databases and the reference lists of the included papers to identify studies in which HF patient data were used to create a predictive model. Literature screening was conducted in Academic Search Ultimate, ERIC, Health Source Nursing/Academic Edition and MEDLINE. The protocol of the current systematic review was registered in the PROSPERO database with the registration number CRD42022344855. We considered all types of outcomes: mortality, rehospitalization, response to treatment and medication adherence. The area under the receiver operating characteristic curve (AUC) was used as the comparator parameter. The literature search yielded 1649 studies, of which 9 were included in the final analysis. The AUCs for the machine learning models ranged from 0.6494 to 0.913 in independent datasets, whereas the AUCs for statistical predictive scores ranged from 0.622 to 0.806. Our study showed an increasing number of ML predictive models concerning HF populations, although external validation remains infrequent. However, our findings revealed that ML approaches can outperform conventional risk scores and may play important role in HF management.
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Affiliation(s)
- Mikołaj Błaziak
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Correspondence: (M.B.); (W.K.); Tel.: +48-71-733-11-12 (M.B.)
| | - Szymon Urban
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Weronika Wietrzyk
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Maksym Jura
- Department of Physiology and Pathophysiology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Gracjan Iwanek
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Bartłomiej Stańczykiewicz
- Department of Psychiatry, Division of Consultation Psychiatry and Neuroscience, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Wiktor Kuliczkowski
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
- Correspondence: (M.B.); (W.K.); Tel.: +48-71-733-11-12 (M.B.)
| | - Robert Zymliński
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Maciej Pondel
- Institute of Information Systems in Economics, Wroclaw University of Economics and Business, 53-345 Wroclaw, Poland
| | - Petr Berka
- Department of Information and Knowledge Engineering, Prague University of Economics and Business, W. Churchill Sq. 1938/4, 130 67 Prague, Czech Republic
| | - Dariusz Danel
- Department of Anthropology, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Agnieszka Siennicka
- Department of Physiology and Pathophysiology, Wroclaw Medical University, 50-368 Wroclaw, Poland
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14
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Hassannataj Joloudari J, Mojrian S, Nodehi I, Mashmool A, Kiani Zadegan Z, Khanjani Shirkharkolaie S, Alizadehsani R, Tamadon T, Khosravi S, Akbari Kohnehshari M, Hassannatajjeloudari E, Sharifrazi D, Mosavi A, Loh HW, Tan RS, Acharya UR. Application of artificial intelligence techniques for automated detection of myocardial infarction: a review. Physiol Meas 2022; 43. [PMID: 35803247 DOI: 10.1088/1361-6579/ac7fd9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/08/2022] [Indexed: 11/11/2022]
Abstract
Myocardial infarction (MI) results in heart muscle injury due to receiving insufficient blood flow. MI is the most common cause of mortality in middle-aged and elderly individuals worldwide. To diagnose MI, clinicians need to interpret electrocardiography (ECG) signals, which requires expertise and is subject to observer bias. Artificial intelligence-based methods can be utilized to screen for or diagnose MI automatically using ECG signals. In this work, we conducted a comprehensive assessment of artificial intelligence-based approaches for MI detection based on ECG and some other biophysical signals, including machine learning (ML) and deep learning (DL) models. The performance of traditional ML methods relies on handcrafted features and manual selection of ECG signals, whereas DL models can automate these tasks. The review observed that deep convolutional neural networks (DCNNs) yielded excellent classification performance for MI diagnosis, which explains why they have become prevalent in recent years. To our knowledge, this is the first comprehensive survey of artificial intelligence techniques employed for MI diagnosis using ECG and some other biophysical signals.
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Affiliation(s)
- Javad Hassannataj Joloudari
- Computer Engineering, University of Birjand, South Khorasan Province, Birjand, Iran, Birjand, South Khorasan, 9717434765, Iran (the Islamic Republic of)
| | - Sanaz Mojrian
- Mazandaran University of Science and Technology, Mazandaran Province, Babol, Danesh 5, No. Sheykh Tabarasi, Iran, Babol, 47166-85635, Iran (the Islamic Republic of)
| | - Issa Nodehi
- University of Qom, Qom, shahid khodakaram blvd، Iran, Qom, Qom, 1519-37195, Iran (the Islamic Republic of)
| | - Amir Mashmool
- University of Geneva, Via del Molo, 65, 16128 Genova GE, Italy, Geneva, Geneva, 16121, ITALY
| | - Zeynab Kiani Zadegan
- University of Birjand, South Khorasan Province, Birjand, Iran, Birjand, 9717434765, Iran (the Islamic Republic of)
| | - Sahar Khanjani Shirkharkolaie
- Mazandaran University of Science and Technology, Mazandaran Province, Babol, Danesh 5, No. Sheykh Tabarasi, Iran, Babol, 47166-85635, Iran (the Islamic Republic of)
| | - Roohallah Alizadehsani
- Deakin University - Geelong Waterfront Campus, IISRI, Geelong, Victoria, 3220, AUSTRALIA
| | - Tahereh Tamadon
- University of Birjand, South Khorasan Province, Birjand, Iran, Birjand, 9717434765, Iran (the Islamic Republic of)
| | - Samiyeh Khosravi
- University of Birjand, South Khorasan Province, Birjand, Iran, Birjand, 9717434765, Iran (the Islamic Republic of)
| | - Mitra Akbari Kohnehshari
- Bu Ali Sina University, QFRQ+V8H District 2, Hamedan, Iran, Hamedan, Hamedan, 6516738695, Iran (the Islamic Republic of)
| | - Edris Hassannatajjeloudari
- Maragheh University of Medical Sciences, 87VG+9J6, Maragheh, East Azerbaijan Province, Iran, Maragheh, East Azerbaijan, 55158-78151, Iran (the Islamic Republic of)
| | - Danial Sharifrazi
- Islamic Azad University Shiraz, Shiraz University, Iran, Shiraz, Fars, 74731-71987, Iran (the Islamic Republic of)
| | - Amir Mosavi
- Faculty of Informatics, Obuda University, Faculty of Informatics, Obuda University, Budapest, Hungary, Budapest, 1034, HUNGARY
| | - Hui Wen Loh
- Singapore University of Social Sciences, SG, Clementi Rd, 463, Singapore 599494, Singapore, 599491, SINGAPORE
| | - Ru-San Tan
- Department of Cardiology, National Heart Centre Singapore, 5 Hospital Dr, Singapore 169609, Singapore, 168752, SINGAPORE
| | - U Rajendra Acharya
- Electronic Computer Engineering Division, Ngee Ann Polytechnic, 535 Clementi Road, Singapore 599489, Singapore, 599489, SINGAPORE
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