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Al-Zaiti SS, Martin-Gill C, Zègre-Hemsey JK, Bouzid Z, Faramand Z, Alrawashdeh MO, Gregg RE, Helman S, Riek NT, Kraevsky-Phillips K, Clermont G, Akcakaya M, Sereika SM, Van Dam P, Smith SW, Birnbaum Y, Saba S, Sejdic E, Callaway CW. Machine learning for ECG diagnosis and risk stratification of occlusion myocardial infarction. Nat Med 2023; 29:1804-1813. [PMID: 37386246 PMCID: PMC10353937 DOI: 10.1038/s41591-023-02396-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/11/2023] [Indexed: 07/01/2023]
Abstract
Patients with occlusion myocardial infarction (OMI) and no ST-elevation on presenting electrocardiogram (ECG) are increasing in numbers. These patients have a poor prognosis and would benefit from immediate reperfusion therapy, but, currently, there are no accurate tools to identify them during initial triage. Here we report, to our knowledge, the first observational cohort study to develop machine learning models for the ECG diagnosis of OMI. Using 7,313 consecutive patients from multiple clinical sites, we derived and externally validated an intelligent model that outperformed practicing clinicians and other widely used commercial interpretation systems, substantially boosting both precision and sensitivity. Our derived OMI risk score provided enhanced rule-in and rule-out accuracy relevant to routine care, and, when combined with the clinical judgment of trained emergency personnel, it helped correctly reclassify one in three patients with chest pain. ECG features driving our models were validated by clinical experts, providing plausible mechanistic links to myocardial injury.
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Affiliation(s)
- Salah S Al-Zaiti
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA.
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Zeineb Bouzid
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ziad Faramand
- Department of Emergency Medicine, Northeast Georgia Health System, Gainesville, GA, USA
| | - Mohammad O Alrawashdeh
- School of Nursing, Jordan University of Science and Technology, Irbid, Jordan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Richard E Gregg
- Advanced Algorithm Development Center, Philips Healthcare, Cambridge, MA, USA
| | - Stephanie Helman
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan T Riek
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Gilles Clermont
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Murat Akcakaya
- Department of Electrical & Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan M Sereika
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter Van Dam
- Division of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Yochai Birnbaum
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Samir Saba
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ervin Sejdic
- Department of Electrical & Computer Engineering, University of Toronto, Toronto, ON, Canada
- Artificial Intelligence for Health Outcomes at Research & Innovation, North York General Hospital, Toronto, ON, Canada
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Al-Zaiti SS, Faramand Z, Alrawashdeh MO, Sereika SM, Martin-Gill C, Callaway C. Comparison of clinical risk scores for triaging high-risk chest pain patients at the emergency department. Am J Emerg Med 2018; 37:461-467. [PMID: 29907395 DOI: 10.1016/j.ajem.2018.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/10/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Many of the clinical risk scores routinely used for chest pain assessment have not been validated in patients at high risk for acute coronary syndrome (ACS). We performed an independent comparison of HEART, TIMI, GRACE, FRISC, and PURSUIT scores for identifying chest pain due to ACS and for predicting 30-day death or re-infarction in patients arriving through Emergency Medical Services (EMS). METHODS AND RESULTS We enrolled consecutive EMS patients evaluated for chest pain at three emergency departments. A reviewer blinded to outcome data retrospectively reviewed patient charts to compute each risk score. The primary outcome was ACS diagnosed during the primary admission, and the secondary outcome was death or re-infarction within 30-days of initial presentation. Our sample included 750 patients (aged 59 ± 17 years, 42% female), of whom 115 (15.3%) had ACS and 33 (4.4%) had 30-day death or re-infarction. The c-statistics of HEART, TIMI, GRACE, FRISC, and PURSUIT for identifying ACS were 0.87, 0.86, 0.73, 0.84, and 0.79, respectively, and for predicting 30-day death or re-infarction were 0.70, 0.73, 0.72, 0.72, and 0.62, respectively. Sensitivity/negative predictive value of HEART ≥ 4 and TIMI ≥ 3 for ACS detection were 0.94/0.98 and 0.87/0.97, respectively. CONCLUSIONS In chest pain patients admitted through EMS, HEART and TIMI outperform other scores for identifying chest pain due to ACS. Although both have similar negative predictive value, HEART has better sensitivity and lower rate of false negative results, thus it can be used preferentially over TIMI in the initial triage of this population.
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Affiliation(s)
- Salah S Al-Zaiti
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, PA, United States; Department of Emergency Medicine, University of Pittsburgh, PA, United States.
| | - Ziad Faramand
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, PA, United States; University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Mohammad O Alrawashdeh
- Department of Acute & Tertiary Care Nursing, University of Pittsburgh, PA, United States; Jordan University of Science and Technology, Irbid, Jordan
| | - Susan M Sereika
- Department of Research & Evaluation, University of Pittsburgh, PA, United States; Department of Biostatistics, University of Pittsburgh, PA, United States
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, PA, United States; University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, PA, United States; University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
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