Enhancing Framingham Cardiovascular Risk Score Transparency through Logic-Based XAI

Sudden cardiac death (SCD) is unpredictable, and its prediction in Chagas cardiomyopathy (CC) remains a significant challenge, especially in patients not classified as high risk. While AI and machine learning models improve risk stratification, their adoption is hindered by a lack of transparency, as they are often perceived as black boxes with unclear decision-making processes. Some approaches apply heuristic explanations without correctness guarantees, leading to mistakes in the decision-making process. To address this, we apply a logic-based explainability method with correctness guarantees to the problem of SCD prediction in CC. This explainability method, applied to an AI classifier with over 95% accuracy and recall, demonstrated strong predictive performance and 100% explanation fidelity. When compared to state-of-the-art heuristic methods, it showed superior consistency and robustness. This approach enhances clinical trust, facilitates the integration of AI-driven tools into practice, and promotes large-scale deployment, particularly in endemic regions where it is most needed.

Background. Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and a major determinant of prognosis. Established AF risk scores rely on factors (older age, hypertension) nearly ubiquitous among patients with cardiovascular disease (CVD), offering limited stratification in this high-risk group. Most target long-term (5-10 year) rather than medium-term prediction. We developed interpretable ML models predicting AF risk over a 24-month and entire follow-up horizon in CVD patients using routinely collected hospital data. Methods. Single-center retrospective study of electronic health records from the National Research Cardiology Center (Russia) for patients aged >=18 with CVD but without pre-existing AF, hospitalized more than once between January 2012 and May 2019. A custom NLP pipeline transformed unstructured discharge reports into 73 structured features, combining a rule-based parser with transformer-based NER. Using LightAutoML we built a full model (73 features), a simple model (reduced subset), and a linear model for a bedside risk score. Performance was assessed by ROC AUC, compared with CHARGE-AF, C2HEST, MHS, and HAVOC, and interpreted via SHAP. Results. Of 80,576 records from 45,000 patients, 17,562 met inclusion criteria; 1,438 (8.19%) developed AF. The full model reached ROC AUC 0.735 (24-month) and 0.696 (entire follow-up); the simple model was nearly identical (0.725, 0.696). All non-linear models outperformed the four clinical risk scores (ROC AUC 0.53-0.64). The simple model uses 13 features and is named Pre-AF 13. SHAP identified age and left atrial volume as dominant predictors. A linear risk score (Pre-AF 9) stratified observed 24-month AF incidence from ~7% to 36%. Conclusion. Interpretable ML models built from routinely collected EHR data identify high-AF-risk CVD patients, outperforming established clinical risk scores.

Cardiovascular screening models trained on national health surveys routinely report areas under the receiver operating characteristic curve (AUROC) near 0.89. We asked whether that accuracy reflects learning or target leakage, whether tabular foundation models change the answer, and whether the properties deployment requires survive joint examination. We benchmarked ten classifiers spanning linear, tree-ensemble, neural, glass-box, and tabular foundation classes for prevalent myocardial infarction in 442,067 respondents of the 2022 Behavioral Risk Factor Surveillance System across five feature tiers of decreasing leakage risk. Each was audited for discrimination, calibration, fairness at an explicit screening threshold, conformal coverage, explanation faithfulness, and inference cost, then applied -- models and thresholds frozen -- to 430,755 respondents of 2023. Removing two post-diagnostic features cost every model 0.049-0.051 AUROC, collapsing the field into a 0.0045-wide band. The glass-box explainable boosting machine was non-inferior to every alternative within a pre-specified 0.005 margin while scoring the cohort roughly 104 times faster than the strongest foundation model. One threshold detected 75.4% of women's infarctions against 89.0% of men's; editing the model's shape functions reduced the gap to 0.010. Marginal conformal prediction gave 0.86 coverage to men and 0.82 to adults over 60; Mondrian calibration repaired every stratum. Frozen models transported within 0.002 AUROC. Reported headroom in this literature is a property of the feature set, not the learner. Transparency cost nothing measurable and made fairness repair and uncertainty conditioning directly auditable. Evaluation practice, not model capacity, is the binding constraint.