Automated Determination of Left Ventricular Function Using Electrocardiogram Data in Patients on Maintenance Hemodialysis

Abstract

Background and objectivesLeft ventricular ejection fraction is disrupted in patients on maintenance hemodialysis and can be estimated using deep learning models on electrocardiograms. Smaller sample sizes within this population may be mitigated using transfer learning.Design, setting, participants, & measurementsWe identified patients on hemodialysis with transthoracic echocardiograms within 7 days of electrocardiogram using diagnostic/procedure codes. We developed four models: (1) trained from scratch in patients on hemodialysis, (2) pretrained on a publicly available set of natural images (ImageNet), (3) pretrained on all patients not on hemodialysis, and (4) pretrained on patients not on hemodialysis and fine-tuned on patients on hemodialysis. We assessed the ability of the models to classify left ventricular ejection fraction into clinically relevant categories of ≤40%, 41% to ≤50%, and >50%. We compared performance by area under the receiver operating characteristic curve.ResultsWe extracted 705,075 electrocardiogram:echocardiogram pairs for 158,840 patients not on hemodialysis used for development of models 3 and 4 and n=18,626 electrocardiogram:echocardiogram pairs for 2168 patients on hemodialysis for models 1, 2, and 4. The transfer learning model achieved area under the receiver operating characteristic curves of 0.86, 0.63, and 0.83 in predicting left ventricular ejection fraction categories of ≤40% (n=461), 41%–50% (n=398), and >50% (n=1309), respectively. For the same tasks, model 1 achieved area under the receiver operating characteristic curves of 0.74, 0.55, and 0.71, respectively; model 2 achieved area under the receiver operating characteristic curves of 0.71, 0.55, and 0.69, respectively, and model 3 achieved area under the receiver operating characteristic curves of 0.80, 0.51, and 0.77, respectively. We found that predictions of left ventricular ejection fraction by the transfer learning model were associated with mortality in a Cox regression with an adjusted hazard ratio of 1.29 (95% confidence interval, 1.04 to 1.59).ConclusionA deep learning model can determine left ventricular ejection fraction for patients on hemodialysis following pretraining on electrocardiograms of patients not on hemodialysis. Predictions of low ejection fraction from this model were associated with mortality over a 5-year follow-up period.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_06_06_CJN16481221.mp3

A foundational vision transformer improves diagnostic performance for electrocardiograms

“…Deep learning has been applied to ECG data for several diagnostic and prognostic use cases 2 – 6 . The vast majority of this work has been built upon Convolutional Neural Networks (CNNs) 7 .…”

Deep Learning on Electrocardiograms for Prediction of In-hospital Intradialytic Hypotension in Patients with ESKD

“…[3][4][5] In addition, in the context of patients with HD who have an increased risk of cardiovascular abnormalities, our previous research has shown that using a deep learning model using ECGs can accurately categorize left ventricular ejection fraction, and predictions of low ejection fraction from our model were significantly associated with increased mortality over a 5-year follow-up period. 6 IDH is a serious HD complication that can lead to increased morbidity and mortality. Identification of patients at risk of IDH is essential because it allows for modifications to their dialysis prescription, such as increased dialysis time or frequency, decreased ultrafiltration, and using cool dialysate.…”

“… 3 – 5 In addition, in the context of patients with HD who have an increased risk of cardiovascular abnormalities, our previous research has shown that using a deep learning model using ECGs can accurately categorize left ventricular ejection fraction, and predictions of low ejection fraction from our model were significantly associated with increased mortality over a 5-year follow-up period. 6 …”