Interpretable Machine Learning Prediction of Drug-Induced QT Prolongation: Electronic Health Record Analysis

Impact of an Alert-Based Inpatient Clinical Decision Support Tool to Prevent Drug-Induced Long QT Syndrome: Large-Scale, System-Wide Observational Study

BACKGROUND

Prevention of drug-induced QT prolongation (diLQTS) has been the focus of many system-wide clinical decision support (CDS) tools, which can be directly embedded within the framework of the electronic health record system and triggered to alert in high-risk patients when a known QT-prolonging medication is ordered. Justification for these CDS systems typically lies in the ability to accurately predict which patients are at high risk; however, it is not always evident that identification of risk alone is sufficient for appropriate CDS implementation.

OBJECTIVE

In this investigation, we examined the impact of a system-wide, alert-based, inpatient CDS tool designed to prevent diLQTS across 10 known QT-prolonging medications.

METHODS

We compared the risk of diLQTS, duration of hospitalization, and in- and out-of-hospital mortality before and after implementation of the CDS system in 178,097 hospitalizations among 102,847 patients. We also compared outcomes between those in whom an alert fired and those in whom it did not, and within the various responses to the alert by providers. Analyses were adjusted for age, sex, race and ethnicity, inpatient location, electrolyte values, and comorbidities, with the latter processed using an unsupervised clustering analysis applied to the top 500 most common medications and diagnosis codes, respectively.

RESULTS

We found that the simple, rule-based logic of the CDS (any prior electrocardiograph with heart rate-corrected QT interval (QTc)≥500 ms) successfully identified patients at high risk of diLQTS with an odds ratio of 2.28 (95% CI 2.10-2.47, P<.001) among those in whom it fired. However, we did not identify any impact on the risk of diLQTS based on provider responses or on the risk of inpatient, 3-month, 6-month, or 1-year mortality. When compared with rates prior to implementation, the risk of diLQTS was not significantly different after the CDS tools were deployed across the system, although mortality was significantly higher after the tools were implemented.

CONCLUSIONS

We found that despite successful identification of high-risk patients for diLQTS, deployment of an alert-based CDS did not impact the risk of diLQTS. These findings suggest that quantification of high risk may be insufficient rationale for implementation of a CDS system and that hospital systems should consider evaluation of the system in its entirety prior to adoption to improve clinical outcomes.

Artificial Intelligence Applications in Cardio-Oncology: A Comprehensive Review

PURPOSE OF REVIEW

This review explores the role of artificial intelligence (AI) in cardio-oncology, focusing on its latest application across problems in diagnosis, prognosis, risk stratification, and management of cardiovascular (CV) complications in cancer patients. It also highlights multi-omics analysis, explainable AI, and real-time decision-making, while addressing challenges like data heterogeneity and ethical concerns.

RECENT FINDINGS

AI can advance cardio-oncology by leveraging imaging, electronic health records (EHRs), electrocardiograms (ECG), and multi-omics data for early cardiotoxicity detection, stratification and long-term risk prediction. Novel AI-ECG models and imaging techniques improve diagnostic accuracy, while multi-omics analysis identifies biomarkers for personalized treatment. However, significant barriers, including data heterogeneity, lack of transparency, and regulatory challenges, hinder widespread adoption. AI significantly enhances early detection and intervention in cardio-oncology. Future efforts should address the impact of AI technologies on clinical outcomes, and ethical challenges, to enable broader clinical adoption and improve patient care.

Deep Neural Network Analysis of the 12-Lead Electrocardiogram Distinguishes Patients With Congenital Long QT Syndrome From Patients With Acquired QT Prolongation

OBJECTIVE

To test whether an artificial intelligence (AI) deep neural network (DNN)-derived analysis of the 12-lead electrocardiogram (ECG) can distinguish patients with long QT syndrome (LQTS) from those with acquired QT prolongation.

METHODS

The study cohort included all patients with genetically confirmed LQTS evaluated in the Windland Smith Rice Genetic Heart Rhythm Clinic and controls from Mayo Clinic's ECG data vault comprising more than 2.5 million patients. For the AI-DNN model, every patient and control with 1 or more ECGs above age- and sex-specific 99th percentile values for QTc (>460 ms for all patients [male/female] <13 years of age or >470 ms for men and >480 ms for women above this age) were included. LQTS patients were age and sex matched to controls at a 1:5 ratio. An AI-DNN involving a multilayer convolutional neural network was developed to classify patients.

RESULTS

Of the 1,599 patients with genetically confirmed LQTS, 808 had 1 or more ECGs with QTc above the defined thresholds (2987 ECGs) compared with 361,069 of 2.5 million controls (14% of Mayo Clinic patients having an ECG, "presumed negative"; 989,313 ECGs). Following age and sex matching and splitting, 3,309 (training), 411 (validation), and 887 (testing) ECGs were used. This model distinguished patients with LQTS from those with acquired QT prolongation with an area under the curve of 0.896 (accuracy 85%, sensitivity 77%, specificity 87%). The model remained robust with areas under the curve close to or above 0.9, independent of matching ratio (range, 1:5 to 1:2000) or type of ECG data used (rhythm strip of median beat) and after excluding patients with wide QRS or ventricular pacemaker.

CONCLUSION

For patients with a QTc exceeding its 99th percentile values, this novel AI-DNN functions as an LQTS mutation detector, being able to identify patients with abnormal QT prolongation secondary to an LQTS-causative mutation rather than with acquired QT prolongation. This algorithm may facilitate screening for this potentially lethal yet highly treatable genetic heart disease.

A polygenic risk score for the QT interval is an independent predictor of drug-induced QT prolongation

Drug-induced QT prolongation (diLQTS), and subsequent risk of torsade de pointes, is a major concern with use of many medications, including for non-cardiac conditions. The possibility that genetic risk, in the form of polygenic risk scores (PGS), could be integrated into prediction of risk of diLQTS has great potential, although it is unknown how genetic risk is related to clinical risk factors as might be applied in clinical decision-making. In this study, we examined the PGS for QT interval in 2500 subjects exposed to a known QT-prolonging drug on prolongation of the QT interval over 500ms on subsequent ECG using electronic health record data. We found that the normalized QT PGS was higher in cases than controls (0.212±0.954 vs. -0.0270±1.003, P = 0.0002), with an unadjusted odds ratio of 1.34 (95%CI 1.17-1.53, P<0.001) for association with diLQTS. When included with age and clinical predictors of QT prolongation, we found that the PGS for QT interval provided independent risk prediction for diLQTS, in which the interaction for high-risk diagnosis or with certain high-risk medications (amiodarone, sotalol, and dofetilide) was not significant, indicating that genetic risk did not modify the effect of other risk factors on risk of diLQTS. We found that a high-risk cutoff (QT PGS ≥ 2 standard deviations above mean), but not a low-risk cutoff, was associated with risk of diLQTS after adjustment for clinical factors, and provided one method of integration based on the decision-tree framework. In conclusion, we found that PGS for QT interval is an independent predictor of diLQTS, but that in contrast to existing theories about repolarization reserve as a mechanism of increasing risk, the effect is independent of other clinical risk factors. More work is needed for external validation in clinical decision-making, as well as defining the mechanism through which genes that increase QT interval are associated with risk of diLQTS.

Computational Approaches for Predicting Preterm Birth and Newborn Outcomes

Preterm birth (PTB) and its associated morbidities are a leading cause of infant mortality and morbidity. Accurate predictive models and a better biological understanding of PTB-associated morbidities are critical in reducing their adverse effects. Increasing availability of multimodal high-dimensional data sets with concurrent advances in artificial intelligence (AI) have created a rich opportunity to gain novel insights into PTB, a clinically complex and multifactorial disease. Here, the authors review the use of AI to analyze 3 modes of data: electronic health records, biological omics, and social determinants of health metrics.

QTNet: Predicting Drug-Induced QT Prolongation With Artificial Intelligence-Enabled Electrocardiograms

BACKGROUND

Prediction of drug-induced long QT syndrome (diLQTS) is of critical importance given its association with torsades de pointes. There is no reliable method for the outpatient prediction of diLQTS.

OBJECTIVES

This study sought to evaluate the use of a convolutional neural network (CNN) applied to electrocardiograms (ECGs) to predict diLQTS in an outpatient population.

METHODS

We identified all adult outpatients newly prescribed a QT-prolonging medication between January 1, 2003, and March 31, 2022, who had a 12-lead sinus ECG in the preceding 6 months. Using risk factor data and the ECG signal as inputs, the CNN QTNet was implemented in TensorFlow to predict diLQTS.

RESULTS

Models were evaluated in a held-out test dataset of 44,386 patients (57% female) with a median age of 62 years. Compared with 3 other models relying on risk factors or ECG signal or baseline QTc alone, QTNet achieved the best (P < 0.001) performance with a mean area under the curve of 0.802 (95% CI: 0.786-0.818). In a survival analysis, QTNet also had the highest inverse probability of censorship-weighted area under the receiver-operating characteristic curve at day 2 (0.875; 95% CI: 0.848-0.904) and up to 6 months. In a subgroup analysis, QTNet performed best among males and patients ≤50 years or with baseline QTc <450 ms. In an external validation cohort of solely suburban outpatient practices, QTNet similarly maintained the highest predictive performance.

CONCLUSIONS

An ECG-based CNN can accurately predict diLQTS in the outpatient setting while maintaining its predictive performance over time. In the outpatient setting, our model could identify higher-risk individuals who would benefit from closer monitoring.

Artificial Intelligence in Diagnosis of Long QT Syndrome: A Review of Current State, Challenges, and Future Perspectives

Long QT syndrome (LQTS) is a potentially life-threatening cardiac repolarization disorder characterized by an increased risk of fatal arrhythmias. Accurate and timely diagnosis is essential for risk stratification and appropriate management. However, traditional diagnostic approaches have limitations, necessitating more objective and efficient tools. Artificial intelligence (AI) offers promising solutions by enhancing the accuracy and efficiency of electrocardiography (ECG) interpretation. The AI algorithms can process ECG data more rapidly than human experts, providing real-time analysis and prompt identification of individuals at risk, and reducing interobserver variability. By analyzing large volumes of ECG data, AI algorithms can extract meaningful features that may not be apparent to the human eye. Advancements in AI-driven corrected QT interval monitoring using mobile ECG devices, such as smartwatches, offer a valuable and convenient tool for identifying individuals at risk of LQTS-related complications, which is particularly applicable during pandemic conditions, such as COVID-19. Integration of AI into clinical practice poses a number of challenges. Bias in data gathering and patient privacy concerns are important considerations that must be addressed. Safeguarding patient privacy and ensuring data protection are crucial for maintaining trust in AI-driven systems. In addition, the interpretability of AI algorithms is a concern because understanding the decision-making process is essential for clinicians to trust and confidently use these tools. Future perspectives in this field may involve the integration of AI into diagnostic protocols, through genetic subtype classifications on the basis of ECG data. Moreover, explainable AI techniques aim to uncover ECG features associated with LQTS diagnosis, suggesting new insights into LQTS pathophysiology.

A Discussion of the Contemporary Prediction Models for Atrial Fibrillation

Atrial Fibrillation is a complex disease state with many environmental and genetic risk factors. While there are environmental factors that have been shown to increase an individual's risk of atrial fibrillation, it has become clear that atrial fibrillation has a genetic component that influences why some patients are at a higher risk of developing atrial fibrillation compared to others. This review will first discuss the clinical diagnosis of atrial fibrillation and the corresponding rhythm atrial flutter. We will then discuss how a patients' risk of stroke can be assessed by using other clinical co-morbidities. We will then review the clinical risk factors that can be used to help predict an individual patient's risk of atrial fibrillation. Many of the clinical risk factors have been used to create several different risk scoring methods that will be reviewed. We will then discuss how genetics can be used to identify individuals who are at higher risk for developing atrial fibrillation. We will discuss genome-wide association studies and other sequencing high-throughput sequencing studies. Finally, we will touch on how genetic variants derived from a genome-wide association studies can be used to calculate an individual's polygenic risk score for atrial fibrillation. An atrial fibrillation polygenic risk score can be used to identify patients at higher risk of developing atrial fibrillation and may allow for a reduction in some of the complications associated with atrial fibrillation such as cerebrovascular accidents and the development of heart failure. Finally, there is a brief discussion of how artificial intelligence models can be used to predict which patients will develop atrial fibrillation.

Machine Learning in Cardio-Oncology: New Insights from an Emerging Discipline

A growing body of evidence on a wide spectrum of adverse cardiac events following oncologic therapies has led to the emergence of cardio-oncology as an increasingly relevant interdisciplinary specialty. This also calls for better risk-stratification for patients undergoing cancer treatment. Machine learning (ML), a popular branch discipline of artificial intelligence that tackles complex big data problems by identifying interaction patterns among variables, has seen increasing usage in cardio-oncology studies for risk stratification. The objective of this comprehensive review is to outline the application of ML approaches in cardio-oncology, including deep learning, artificial neural networks, random forest and summarize the cardiotoxicity identified by ML. The current literature shows that ML has been applied for the prediction, diagnosis and treatment of cardiotoxicity in cancer patients. In addition, role of ML in gender and racial disparities for cardiac outcomes and potential future directions of cardio-oncology are discussed. It is essential to establish dedicated multidisciplinary teams in the hospital and educate medical professionals to become familiar and proficient in ML in the future.