Machine Learning to Predict 10-year Cardiovascular Mortality from the Electrocardiogram: Analysis of the Third National Health and Nutrition Examination Survey (NHANES III)

BackgroundThe value of the electrocardiogram (ECG) for predicting long-term cardiovascular outcomes is not well defined. Machine learning methods are well suited for analysis of highly correlated data such as that from the ECG. MethodsUsing demographic, clinical, and 12-lead ECG data from the Third National Health and Nutrition Examination Survey (NHANES III), machine learning models were trained to predict 10-year cardiovascular mortality in ambulatory U.S. adults. Predictive performance of each model was assessed using area under receiver operating characteristic curve (AUROC), area under precision-recall curve (AUPRC), sensitivity, and specificity. These were compared to the 2013 American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE). Results7,067 study participants (mean age: 59.2 {+/-} 13.4 years, female: 52.5%, white: 73.9%, black: 23.3%) were included. At 10 years of follow up, 338 (4.8%) had died from cardiac causes. Compared to the PCE (AUROC: 0.668, AUPRC: 0.125, sensitivity: 0.492, specificity: 0.859), machine learning models only required demographic and ECG data to achieve comparable performance: logistic regression (AUROC: 0.754, AUPRC: 0.141, sensitivity: 0.747, specificity: 0.759), neural network (AUROC: 0.764, AUPRC: 0.149, sensitivity: 0.722, specificity: 0.787), and ensemble model (AUROC: 0.695, AUPRC: 0.166, sensitivity: 0.468, specificity: 0.912). Additional clinical data did not improve the predictive performance of machine learning models. In variable importance analysis, important ECG features clustered in inferior and lateral leads. ConclusionsMachine learning can be applied to demographic and ECG data to predict 10-year cardiovascular mortality in ambulatory adults, with potentially important implications for primary prevention.