Machine learning of microvolt-level 12-lead electrocardiogram can help distinguish takotsubo syndrome and acute anterior myocardial infarction

BACKGROUND: Qualitative differences in 12-lead electrocardiograms (ECG) at onset have been reported in patients with takotsubo syndrome (TTS) and acute anterior myocardial infarction (Ant-AMI). We aimed to distinguish these diseases by machine learning (ML) approach of microvolt-level quantitative measurements. METHODS: We enrolled 56 consecutive patients with sinus rhythm TTS (median age, 77 years; 16 men), and 1-to-1 random matching was performed based on age and sex of the patients. The ECG in the emergency room was evaluated using an automated system (ECAPs12c; Nihon-Koden). Statistical and ML predictive models for TTS were constructed using clinical features and ECG parameters. RESULTS: Statistically significant differences were observed in 25 parameters; the V(1) ST level at the J point (V(1) STJ) showed the lowest P value (P < .001). V(1) STJ ≤+18 μV showed the highest accuracy for TTS (0.773). The highest area under the receiver operating characteristic curve (AUROC) was shown in the aVR ST level at 1/16th of the preceding R-R interval after the J point (aVR STmid: 0.727). Conversely, the light gradient boosting machine (model_LGBM) and extra tree classifier (model_ET) indicated higher accuracy (model_LGBM: 0.842, model_ET: 0.831) and AUROC (model_LGBM: 0.868, model_ET 0.896) than other statistical models. V(1) STJ had high feature importance and Shapley additive explanation values in the 2 ML models. CONCLUSION: ML applied to automated microvolt-level ECG measurements showed the possibility of distinguishing between TTS and Ant-AMI, which may be a clinically useful ECG-based discriminator.