Artificial intelligence-guided detection of under-recognized cardiomyopathies on point-of-care cardiac ultrasound: a multi-center study

Abstract

Background: Point-of-care ultrasonography (POCUS) enables cardiac imaging at the bedside and in communities but is limited by abbreviated protocols and variation in quality. We developed and tested artificial intelligence (AI) models to automate the detection of under-diagnosed cardiomyopathies from cardiac POCUS.
Methods: In a development set of 290,245 transthoracic echocardiographic videos across the Yale-New Haven Health System (YNHHS), we used augmentation approaches and a customized loss function weighted for view quality to derive a POCUS-adapted, multi-label, video-based convolutional neural network (CNN) that discriminates HCM (hypertrophic cardiomyopathy) and ATTR-CM (transthyretin amyloid cardiomyopathy) from controls without known disease. We evaluated the final model across independent, internal and external, retrospective cohorts of individuals who underwent cardiac POCUS across YNHHS and Mount Sinai Health System (MSHS) emergency departments (EDs) (2011-2024) to prioritize key views and validate the diagnostic and prognostic performance of single-view screening protocols.
Findings: We identified 33,127 patients (median age 61 [IQR: 45-75] years, n=17,276 [52.2%] female) at YNHHS and 5,624 (57 [IQR: 39-71] years, n=1,953 [34.7%] female) at MSHS with 78,054 and 13,796 eligible cardiac POCUS videos, respectively. An AI-enabled single-view screening approach successfully discriminated HCM (AUROC of 0.90 [YNHHS] & 0.89 [MSHS]) and ATTR-CM (YNHHS: AUROC of 0.92 [YNHHS] & 0.99 [MSHS]). In YNHHS, 40 (58.0%) HCM and 23 (47.9%) ATTR-CM cases had a positive screen at median of 2.1 [IQR: 0.9-4.5] and 1.9 [IQR: 1.0-3.4] years before clinical diagnosis. Moreover, among 24,448 participants without known cardiomyopathy followed over 2.2 [IQR: 1.1-5.8] years, AI-POCUS probabilities in the highest (vs lowest) quintile for HCM and ATTR-CM conferred a 15% (adj.HR 1.15 [95%CI: 1.02-1.29]) and 39% (adj.HR 1.39 [95%CI: 1.22-1.59]) higher age- and sex-adjusted mortality risk, respectively.
Interpretation: We developed and validated an AI framework that enables scalable, opportunistic screening of treatable cardiomyopathies wherever POCUS is used.