Atrial Fibrillation

In the VTaC benchmark 71% of ventricular-tachycardia alarms are false, but silencing a real one can delay recognition of a dangerous arrhythmia. We reframe alarm reduction as three-way triage (retain, suppress, or defer) and bound the decision this analysis treats as harmful: among suppressed alarms, the fraction that were genuine stays below a user-set budget with 95% confidence, under i.i.d. event sampling. Alarms sharing a waveform record are dependent, so the clustered analysis is a sensitivity check. On the official split a 5% budget certifies in all three seeds, suppressing 74.8% of false alarms while silencing 1.5% of genuine ones, at AUROC 0.953 and Challenge Score 83.33, numerically comparable to the strongest of the eleven published systems. Our central finding measures what multiplicity costs: the correction charges for every candidate, so a finer grid can certify strictly less. Under held-out calibration the 885-cell grid we declared certifies 1 of 15 fold-runs, while choosing the grid on a separate selection partition certifies 8. We project the calibration volume each budget needs, making an uncertifiable budget a design parameter. Finally, adding a learned reliability dimension to the policy grid did not sharpen the certified frontier.

False ventricular tachycardia (VT) alarms are a leading contributor to alarm fatigue in intensive care units. We propose a deep learning framework combining a 1D SE-ResNet with ICU-realistic data augmentations and a physics-informed auxiliary reconstruction task based on the three-element Windkessel hemodynamic model, implemented as a differentiable forward simulation. By requiring the network's latent representation to produce physiologically plausible arterial pressure waveforms, artifact-driven ECG patterns are penalized while true VT remains coherent across modalities. Evaluated on the VTaC benchmark under a strict real-time protocol (10-second pre-alarm window), our method achieves a 5-point Challenge Score improvement over prior state-of-the-art. Ablation studies confirm that the physics-informed objective is the primary performance driver, providing gains in accuracy, 2x label efficiency, and more localized and clinically meaningful ECG segments.

Adaptive conformal prediction can recover clinically important heartbeat classes missed by a point classifier, but delayed feedback makes its decisions sensitive to event order. We introduce ConformalShift, a bounded event-reordering attack that suppresses the ventricular class for rescued events without modifying ECG waveforms, labels, classifier scores, or the event multiset. ConformalShift searches for feasible permutations of authentic preceding events that lower the ventricular threshold before a selected target is evaluated. On disjoint MIT--BIH confirmation records, the attack suppressed 66.7% of eligible targets for Extra Trees and 60.0% for HistGradientBoosting, compared with random-schedule rates of 4.4% and 12.0%, respectively. Transferred configurations also outperformed random scheduling on INCART, while reducing the displacement budget weakened the attack on both datasets. These results show that adaptive monitors in healthcare can be compromised through the timing of authentic information, even when waveforms, labels, classifier outputs, and event contents remain unchanged.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with increased risks of stroke, heart failure, and mortality. Recent ECG foundation models offer transferable representations for automated AF detection. However, their relative effectiveness remains unclear because existing studies use different datasets, preprocessing procedures, classifiers, and validation protocols. This study presents FOUND-AF, a unified, leakage-controlled, and deployment-oriented benchmarking framework that evaluates the quality of pretrained ECG representations under identical experimental conditions. Nine publicly available foundation models from five families, including HuBERT-ECG, CLEF, ST-MEM, ECG-JEPA, and ECGFounder, were evaluated across four heterogeneous ECG datasets, namely AFDB, CinC2017, CPSC2021, and LTAFDB. All models were used as frozen feature extractors with standardized preprocessing, model-native resampling, a fixed XGBoost classifier, and recording-level grouped cross-validation. The evaluation included classification metrics, receiver operating characteristic analysis, paired recording-level bootstrap comparisons with Holm correction, embedding-space visualization, and computational efficiency profiling. The ECGFounder model consistently achieved the strongest overall performance across datasets while offering a favorable trade-off between accuracy, model size, inference time, and memory usage. FOUND-AF therefore provides a reproducible framework for selecting ECG foundation models and demonstrates that compact, clinically pretrained encoders can support robust and computationally efficient AF detection across heterogeneous acquisition settings.

The same episode of atrial fibrillation is a minor finding in a healthy adult and grounds for anticoagulation in an elderly patient with hypertension: identical signal, opposite decision. Naming the rhythm is only the start; what determines a patient's outcome is the judgement that follows -- what the arrhythmia is across the whole record, what it means for this patient, and what should be done about it. Recent work pairing large language models with the ECG stops short of this, reading one recording without assembling a patient-level finding; and agentic systems built around it either receive the arrhythmia a device has already detected or target a different diagnostic task, stopping before the decision this task requires. We formulate patient-level arrhythmia decision support as a task and present Cardiologent, a multi-agent system that spans it from detection to decision. An agent for each signal -- a single ECG lead and the photoplethysmogram a wearable acquires -- grounds its window reading in measured features rather than a bare label; the readings are assembled into the patient's rhythm profile and, with the patient's own data, reasoned against clinical guidelines retrieved for the case, with a critic checking each conclusion against the guideline it cites. We evaluate the clinical decision rather than the report, across integrated diagnosis, clinical significance, and urgency and management. Cardiologent scores highest on every axis, first on every patient-level task under both cardiologists and an at-scale LLM judge -- whose agreement with the cardiologists (ICC 0.74, 0.66) matches theirs with each other (0.67). Because each conclusion traces to a cited guideline and is validated against expert cardiologists, it yields decisions a clinician can audit rather than act on blindly -- a step toward use in continuous monitoring.

Deep learning models for ECG image classification may achieve high accuracy by exploiting non-physiological visual cues instead of ECG waveform morphology. Given the black-box nature of deep learning models, their promise of high predictive performance often remains insufficiently translated into clinical or real-world trust, interpretability, and actionable decision-making. In this study, we examine shortcut learning and Clever Hans effect in a publicly available ECG image dataset using convolutional neural networks. In process we have created six image-derived feature sets (FSs), FS1: raw full ECG images, FS2: cropped waveform-only images, FS3: waveform-masked metadata images, FS4: red-arrow artifact images for the myocardial infarction class, FS5: contrast-enhanced images for the abnormal heartbeat class and FS6: Gaussian-blurred images for the normal class. These controlled representations were used to test whether classification performance persists when waveform information is removed or when artificial class-specific artifacts are introduced. Shortcut retention score, prediction consistency and confidence divergence across Feature-Set Representations have been calculated to assess the transparency about the learning pattern. Along with factual results, average Integrated Gradients and occlusion sensitivity test results are presented to inspect whether model attribution focused on ECG-relevant waveform regions or on non-clinical artifacts. Performance changes across feature sets and attribution patterns were used to identify potential Clever Hans behavior. This study evaluates whether ECG image classifiers learn clinically meaningful morphology or shortcut cues introduced by report layout, metadata, contrast, blur, or artificial markers.

Cardiovascular diseases are the leading cause of death worldwide, and conditions such as arrhythmia often require long-term monitoring for effective detection and diagnosis. However, current wearable monitoring devices are bulky, uncomfortable, and typically rely on clinicians to manually evaluate electrocardiograms (ECGs). While Deep Learning (DL) algorithms have shown superior performance in arrhythmia detection and classification, their computational complexity coupled with high power consumption limit deployment in wearable devices. To address this challenge, this paper investigates the use of approximation techniques to reduce the power and energy consumption of DL architectures while maintaining acceptable classification performance. Specifically, techniques such as data precision reduction and approximate multiplication are investigated in a state-of-the-art DL model and its corresponding hardware architecture. The model is trained and validated using the MIT-BIH Arrhythmia Database, and hardware implementations employing various approximate multipliers are synthesized and evaluated. Compared with the state-of-the-art 8.75 μW (and 2.08 μJ) reference architecture, our proposed architecture consumes 3.07 μW (and 2.17 μJ) at 12 kHz, showing 64.9% reduction in power consumption while providing an acceptable output quality, i.e., 93.7% classification accuracy and 92.1% sensitivity. At 100 MHz, our proposed architecture consumes 9.45 mW (and 0.8 μJ), showing 61.5% reduction in energy consumption as compared to the state-of-the-art architecture. These results demonstrate that our proposed approximations significantly extend wearable device battery life while preserving the required arrhythmia classification performance.

Long-tailed label distributions reduce the reliability of deep learning for electrocardiogram (ECG) arrhythmia diagnosis, particularly for clinically important but rare abnormalities. Existing rebalancing and logit adjustment methods mainly address class frequency while overlooking direction-dependent morphological variability across ECG classes. This study proposes Angular Gaussian Supervised Contrastive Learning (AG-SCL) for long-tailed multi-label ECG diagnosis. AG-SCL integrates three components into a unified framework: an Angular Gaussian contrastive branch that models full-covariance class uncertainty on unit-normalized embeddings, Adaptive Logit Adjustment that learns bounded label-state-specific prior corrections instead of fixed frequency-based margins, and tail-aware augmentation that generates morphology-preserving views while protecting the 7-25 Hz QRS-dominant band. The method was evaluated on the public PTB-XL benchmark and a nocturnal ECG dataset comprising 1317 hours of recordings from 141 subjects. AG-SCL achieved the best macro-level performance on both datasets. On PTB-XL, it obtained a balanced accuracy of 0.838, sensitivity of 0.709, specificity of 0.968, mean average precision of 0.495, and TPR at 5% FPR of 0.778. On Noc-ECG, the corresponding values were 0.918, 0.889, 0.947, 0.488, and 0.900. The largest gains occurred in rare or morphologically unstable rhythm classes, while ablation studies confirmed the contributions of full-covariance modelling, Adaptive Logit Adjustment, and tail-aware augmentation. AG-SCL improves long-tailed ECG diagnosis by combining prior calibration with anisotropic representation learning, enhancing sensitivity to rare arrhythmias while maintaining clinically relevant specificity. Our code is available at: https://github.com/Open-EXG/AG-SCL-for-Long-Tailed-ECG.

Arrhythmogenic left ventricular cardiomyopathy is a genetic myocardial disease difficult to diagnose due to the lack of gold standard criteria. Simultaneous PET/MR imaging, combined with multiparametric quantitative analysis, could facilitate the identification of different profiles related to the phenotype and progression of cardiomyopathy. This preliminary study focuses on a methodological strategy for dealing with PET/MRI data, including inter-patient data linkage and regional analysis. Two-step clustering was applied to T1 and T2 maps, LGE, and 18F-FDG-PET images of 99 patients genetically diagnosed with arrhythmogenic left ventricular cardiomyopathy. Each patient's images were independently z-scored and summed into a single volume, which was clustered into supervoxels. Thirty-two inter-patient groups of supervoxels were obtained by spectral clustering. An "abnormality" score was assigned to each cluster and modality, and used to visualise abnormal regions likely associated with disease. They enabled the generation of automated textual and bullseye health reports for each patient, which were compared with cardiac imager assessments using balanced accuracy in repeated nested cross-validation. This approach was further validated on a larger cohort of 167 numerical phantoms. The reports generated by clustering accurately identified most of the cardiac physicians' observations (BA = 0.76 $\pm$ 0.04 in repeated nested cross-validation on patients, and BA $\ge$ 0.8 on phantoms). Furthermore, the identified abnormal clusters closely matched their visual observations, facilitating the identification of varying degrees of fibrosis or inflammation on the images. This approach enables a more systematic handling of multimodal PET/MRI data to characterise myocardial heterogeneity in arrhythmogenic left ventricular cardiomyopathy patients.

Dynamic contrast-enhanced cardiac CT enables time-resolved analysis of contrast filling and washout in the left atrium (LA) and left atrial appendage (LAA), with potential applications for assessing blood stasis in atrial fibrillation (AF). Accurate segmentation across all frames is required for such analysis but is challenging due to large temporal contrast variations and the use of a single annotation per registered sequence. This creates a trade-off between training for robustness and limiting label noise. In this study, we investigate how temporal training-set design affects nnUNet-based segmentation of the LA and LAA in dynamic 4DCT. We compare training using a minimal two-frame dataset reflecting standard clinical practice, a physiologically selected subset of frames, and the full 27-frame sequence. We further evaluate the impact of foreground-based normalization. Training with all frames yielded the best performance in early low-contrast phases. However, the physiologically selected subset achieved comparable performance from the filling phase onward. Applying normalization parameters derived from the full dataset improved performance of reduced datasets in low-contrast frames, but did not fully close the gap. These findings highlight the importance of temporal diversity in training data for robust segmentation in dynamic CT, while indicating that carefully selected frame subsets may provide an effective trade-off between performance and efficiency for downstream applications.

Contrastive representation learning struggles on physiological signals when each subject contributes a distinct baseline pattern. If class differences overlap with subject differences,class-level objectives such as supervised contrastive learning tend to merge per-subject structure into a single per-class cluster,removing the individual variation that a model needs to generalize to unseen patients. We study this problem in the setting of Paroxysmal Atrial Fibrillation(PAF) detection from RR-interval(RRI) sequences and propose a patient-aware contrastive objective that forms positive pairs only from same-patient, same-class segments, preserving each patient's own sinus rhythm(SR) baseline while still pushing the two classes apart. Examining the learned embeddings directly, our objective achieves the most consistent per-patient SR structure (cohesion $0.850$ vs. $0.800$ for supervised contrastive loss (SupCon) and $0.772$ for binary cross-entropy (BCE)). We also identify that BCE produces the cleanest global class separation yet the most disordered per-patient structure. This is precisely why a linear probe trained on its features breaks down on unseen patients. On the IRIDIA-AF dataset, the resulting representation reaches a patient-independent Area Under the Receiver Operating Characteristic Curve (AUROC) of $0.989 \pm 0.003$ with $2.6\times$ lower seed variance than supervised contrastive baselines.These results highlight that per-subject geometric consistency, rather than global class separability, is key to robust cross-patient generalization.

Detecting when a nonlinear dynamical system departs from its normal regime is a recurring problem across the sciences, from cardiology to climate and energy systems. We show that a very simple Kolmogorov--Smirnov test on the output weights of a reservoir computer is highly sensitive to regime changes in nonlinear dynamical systems, including those invisible to both classical nonlinear measures and modern deep-learning detectors. The core idea of our algorithm is to treat the readout layer of a reservoir computer as a representation of the input dynamics. Since the input mapping and the reservoir itself are random and fixed, the trained output weights are the only object encoding the system at hand. We summarize this fingerprint by the empirical cumulative distribution function of the readout weights and compare it to a reference band built from the training data. This unsupervised, online detector distinguishes two visually indistinguishable butterfly-shaped attractors, resolves parameter drifts seven times smaller than the strongest deep-learning baseline, flags noise four orders of magnitude below the signal, and identifies ventricular flutter in a clinical ECG recording. More broadly, we aim to establish a perspective on reservoir computers in which the trained output weights are treated as a representation of the learned system in their own right, rather than merely as a means to forecasting.

Ventricular tachycardia is a life-threatening rhythm disorder and a major cause of sudden cardiac death. Pace-mapping is a clinical procedure for identifying the intervention target during catheter ablation of VT. It requires clinicians to pace different sites in the ventricles and rapidly interpret the resulting electrocardiograms to determine where to pace next or whether a target site has been identified. Active learning AI models have been proposed to guide clinicians to the next pacing site, showing promise in reducing the number of pacing sites and improving the efficiency of pace-mapping. Existing methods require retraining each target without the ability to transfer knowledge across multiple VTs within the same patient or across patients. We introduce cAPM for continuous AI-assisted pace-mapping to capture and transfer knowledge accumulated from past pace-mapping data to reduce the number of pace-mapping data needed for future target VTs. This is made possible by a task-agnostic surrogate neural network that learns the mapping from pacing sites to 12-lead ECG morphology, an active-learning strategy that refines this surrogate model by selecting the most informative pacing site for each target, and a continual learning strategy to do so sequentially while retaining knowledge from prior targets. Evaluated on an in-silico testbed consisting of sequentially-presented localization tasks across different physiological conditions and ventricular geometries, cAPM with and without replay of past data samples achieved an 81% probability of localizing within clinical tolerance (5 mm accuracy) using 4.5 pace-mapping sites, compared to the state-of-the-art active-learning method achieving 38% probability using 13.7 pacing sites. These results provide a strong basis for preparing cAPM towards in-vivo preclinical and clinical studies where it can be used to guide pace-mapping.

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.

Objective: Accurate classification of physiological signals in real-world deployments is challenged by sensor noise, motion artifacts, and distribution shifts between training and deployment data. Inference-time augmentation (ITA), which applies augmentations during inference rather than retraining, offers a simple, model-agnostic mechanism to improve robustness. However, ITA application to physiological signals has remained narrow in scope, relying on limited augmentation methods with fixed, unoptimized parameters. This work proposes a unified ITA framework to address that gap. Approach: The framework incorporates 13 augmentation methods spanning time-domain, amplitude-domain, frequency-domain, and artifact-injection transformations, with hyperparameters optimized via Bayesian optimization. We evaluate on atrial fibrillation (AF) detection from 30-second PPG signals using GPT-PPG and ResNet across five datasets comprising more than 400 patients and ${\sim}$9,800 hours of recording. Main results: Standard ITA consistently improved AUROC (up to 8.5% for GPT-PPG and 0.7% for ResNet) and AUPRC (up to 10.6% for GPT-PPG and 0.8% for ResNet). Selective ITA further reduced average FPR by up to 4.4% (GPT-PPG) and 1.3% (ResNet) on non-AF datasets. Significance: These findings establish ITA as a practical, model-agnostic approach for improving PPG-based AF classification reliability in deployment settings where retraining is not feasible, with broader applicability to physiological signal analysis.

Cardiac motion over a cardiac cycle is crucial for quantifying regional function and is strongly affected by cardiovascular diseases. Since temporally dense mesh sequences are difficult to obtain in practice, we focus on leveraging the more accessible end-diastolic frame to infer a full-cycle sequence. Due to strong regional and disease-specific differences, traditional methods often oversmooth the data by relying on generative models that are optimized for global patterns. To address this problem, we propose Region-Aware and Phenotype-Adaptive Bi-Ventricular Cardiac Motion Synthesis (RePCM) for single frame Bi-ventricular mesh motion completion. In Stage I, a reconstruction network learns vertex wise motion descriptors and clustering yields a data driven functional partition, providing an explicit motion derived region structure. In Stage II, a Region-Specific Injection Module enforces masked, synchronized region exchange within a conditional VAE, preserving localized specific dynamics and restricting cross-region mixing. A Phenotype-Adaptive Mixture-of-Experts prior conditioned on ED shape uses anatomy-guided cues to model latent motion trends and capture inter-disease variability. Experiments on three datasets covering different cardiovascular diseases show consistent gains in geometric and functional metrics and improved preservation of region specific dynamics.

Beat-level Electrocardiography (ECG) arrhythmia detection aims to assign an arrhythmia class to each beat in a recording, yet many existing systems treat beats as isolated local instances. This is limiting because beat labels often depend on multi-beat rhythm context, including timing, compensatory pauses, and beat-to-beat morphological consistency. We present DeepArrhythmia, a tool-grounded multimodal framework for segment-contextualized beat-level ECG arrhythmia classification. Given a multi-beat ECG segment, DeepArrhythmia combines the raw ECG signal and a rendered waveform image, localizes R peaks to identify beat instances, and produces structured beat-level predictions. The framework decouples physiological measurement from evidence integration using specialized tools for beat localization, numerical rhythm--morphology extraction, and morphology-focused textual analysis. DeepArrhythmia uses segment-level confidence to route between minimal and rich evidence states, since richer physiological evidence is not uniformly useful. This agentic design integrates rhythm context, explicit physiological grounding, and selective evidence acquisition for decision making.

Accurate forward modelling is essential for non-invasive cardiac electrophysiology, particularly in atrial fibrillation, where electrical activation is highly disorganised. Conventional physics-based forward models require explicit specification of intracellular conductivity tensors, which are not directly measurable in clinical practice and introduce structural modelling errors. This proof-of-concept study presents a deep learning approach that learns a direct mapping from left atrial intracellular electrical potentials to far-field ECGs without requiring explicit intracellular conductivity inputs at inference time. Despite training only on 74 subjects, the model achieved an R2 of 0.949 \pm 0.037, highlighting potential to reduce structural uncertainty and improve non-invasive AF assessment.

Objective: Atrial fibrillation (AF) is the most common cardiac arrhythmia experienced by intensive care unit (ICU) patients and can cause adverse health effects. In this study, we publish a labelled ICU dataset and benchmarks for AF detection. Methods: We compared machine learning models across three data-driven artificial intelligence (AI) approaches: feature-based classifiers, deep learning (DL), and ECG foundation models (FMs). This comparison addresses a critical gap in the literature and aims to pinpoint which AI approach is best for accurate AF detection. Electrocardiograms (ECGs) from a Canadian ICU and the 2021 PhysioNet/Computing in Cardiology Challenge were used to conduct the experiments. Multiple training configurations were tested, ranging from zero-shot inference to transfer learning. Results: On average and across both datasets, ECG FMs performed best, followed by DL, then feature-based classifiers. The model that achieved the top F1 score on our ICU test set was ECG-FM through a transfer learning strategy (F1=0.89). Conclusion: This study demonstrates promising potential for using AI to build an automatic patient monitoring system. Significance: By publishing our labelled ICU dataset (LinkToBeAdded) and performance benchmarks, this work enables the research community to continue advancing the state-of-the-art in AF detection in the ICU. https://physionet.org/content/kingston-icu-af/