A Closer Look at Mortality Risk Prediction from Electrocardiograms

Abstract: Several recent studies combine large private ECG databases with AI to predict patient mortality. These studies typically use a few, highly variable, modeling approaches. While benchmarking these approaches has historically been limited by a lack of public ECG datasets, this changed with the 2023 release of MIMIC-IV, containing 795,546 ECGs from a U.S. hospital system, and the 2020 release of Code-15, containing 345,779 ECGs collected during routine care in Brazil. We benchmark over 500 AI-ECG survival models predicting all-cause mortality on Code-15 and MIMIC-IV with 2 neural architectures, 4 Deep-Survival-Analysis approaches, and classifiers predicting mortality at 4 time horizons. We extend the highest-performing approach to a dataset from Boston Children's Hospital (BCH, 225,379 ECGs). Models train with and without demographics (age/sex) and evaluate across datasets. The best performing Deep-Survival-Analysis models trained with ECG and demographics yield good median Concordance Indices (Code-15: 0.82, MIMIC-IV: 0.78, BCH: 0.76) and AUPRC scores (median 1-yr/5-yr, Code-15: 0.07/0.15; MIMIC-IV: 0.45/0.55; BCH: 0.04/0.13) considering the percentage of ECGs linked to mortality (1-yr/5-yr, Code-15: 1.2%/3.4%; MIMIC-IV: 14.8%/24.5%; BCH: 0.9%/4.8%). Contrasting with Deep-Survival-Analysis models, classifier-based AI-ECG models exhibit significant, site-dependent sensitivity to the choice of time horizon (median Pearson's R, Code-15: 0.69, p<1E-5; MIMIC-IV: -0.80 p<1E-5). Demographic-only models perform surprisingly well on Code-15. Concordance drops 0.03-0.24 on external validation. We recommend Deep-Survival-Analysis over Classifier-Cox approaches and the inclusion of demographic covariates in ECG survival modeling. Comparisons to demographic-only and baseline models is crucial. External evaluations support fine-tuning models on site-specific data.