Diagnosing diastolic dysfunction using explainable advanced electrocardiography

BACKGROUND AND AIMS Diastolic dysfunction of the left ventricle is a precursor to heart failure with preserved ejection fraction (HFpEF). Detection by electrocardiography (ECG) when asymptomatic (stage B heart failure) would be valuable. We hypothesised that an explainable advanced ECG (A-ECG) score derived from standard 12-lead ECG could accurately diagnose diastolic dysfunction. METHODS Included patients had undergone resting 12-lead ECG and echocardiography demonstrating normal systolic function, with at most mild valve disease, and either the presence (n=150) or absence (n=264) of grade II or III diastolic dysfunction. Stepwise multivariable logistic regression was used to generate an A-ECG score that was crossvalidated using bootstrapping. RESULTS A 6-measure A-ECG score was able to identify diastolic dysfunction with an area under the receiver operating characteristics curve [95% confidence interval] of 0.91 [0.88-0.94], sensitivity 83 [76-91]%, specificity 87 [77-92]%, positive predictive value 78 [69-85]%, negative predictive value 90 [86-94]%, positive likelihood ratio 6.38 [3.30-11.38] and inverse negative likelihood ratio 5.12 [3.21-10.22]. CONCLUSIONS Standard 12-lead ECG can be used to accurately identify diastolic dysfunction by echocardiography via A-ECG. This may have clinical utility for early identification of patients who may benefit from further cardiac assessment and risk factor management to prevent progression to symptomatic heart failure. ### Competing Interest Statement TTS is owner and founder of Nicollier-Schlegel SARL, which performs ECG interpretation consultancy using software that can quantify the advanced ECG measures used in the current study. TTS and MU are founders of Advanced ECG Systems, a company that is developing commercial applications of advanced ECG technology used in the current study. RK has a financial interest in Advanced ECG Systems through being married to MU. ### Funding Statement This study was funded in part by grants to MU from New South Wales Health, Heart Research Australia, and the University of Sydney. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study received ethics approval from the Sydney Local Health District Ethics Board (X19-0286 & 2019/ETH12064) with a retrospective waiver of informed consent. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data underlying this article can be made available upon reasonable request to the corresponding author.