External validation of an electrocardiography artificial intelligence-generated algorithm to detect left ventricular systolic function in a general cardiac clinic in Uganda

Abstract Background Left ventricular systolic dysfunction (LVSD) is associated with increased morbidity and mortality. Although there are effective treatments for patients with LVSD to prevent mortality, heart failure and to improve symptoms, many patients remain undetected and untreated. We have recently derived a deep learning algorithm to detect LVSD using the electrocardiogram (ECG) which could have an important screening role, particularly in limited resources settings. We evaluated the accuracy of this algorithm for the first time in Africa in a sample of subjects attending a cardiology clinic. Methods We conducted a retrospective study in a general cardiac clinic in Uganda. Consecutive patients ≥18 years who had a digital ECG and echocardiogram done within two days of each other were included. We excluded patients with pacemakers or missing information regarding left ventricular ejection fraction (LVEF). Routine 10-second, twelve-lead surface rest ECG were performed using an Edan PC ECG Model SE-1515, Hamburg, Germany. The probability of LVSD was estimated with the Mayo Clinic artificial intelligence (AI) ECG algorithm. LVEF was calculated by the MMode (Teichholz method) using a Philips Ultrasound system, HD7XE, Bothel, Washington, USA. LVSD was defined as a LVEF≤35%. We assessed the overall diagnostic performance of the algorithm to identify LVSD in this population with the area under the receiver operating curve (AUC), and estimated sensitivity, specificity and accuracy using a pre-specified cut-off based on the probability for LVSD generated by the algorithm. We conducted secondary analyses using different LVEF cutoff values. Results We included 634 subjects, 32% (200) of whom had hypertension and 12% (77) clinical heart failure. Mean age was 57±18.8 years, 58% were women and the overall prevalence of LVSD was 4%. The AI-ECG had an AUC of 0.866 (see figure below), sensitivity 73.08%, specificity 91.10%, negative predictive value 98.75%, positive predictive value 26.03% and an accuracy of 90.96% using the original threshold. Using the optimal cutoff based on the AUCs, the sensitivity was 80.77% and specificity was 81.05% with a negative predictive value of 98.99%. The ROC for the detection of LVEF of 40% or below was 0.821. Conclusion The Mayo AI-ECG algorithm demonstrated good accuracy, sensitivity and specificity to detect LVSD in patients seen in a clinical setting in Uganda. This tool may facilitate the identification of people at a high risk for LVSD in settings with low resources. ROC Funding Acknowledgement Type of funding source: None