Towards Automated Diagnosis of Inherited Arrhythmias: Combined Arrhythmia Classification Using Lead-Aware Spatial Attention Networks
This work addresses automated ECG screening for inherited arrhythmias like ARVC and LQTS, which are associated with sudden cardiac death, offering a clinically interpretable tool with state-of-the-art results, though it is incremental as it builds on existing deep learning and foundation model approaches.
The researchers tackled multi-class inherited arrhythmia classification from ECGs by developing lead-aware spatial attention networks integrated with foundation models, achieving near-ceiling performance with macro-AUROC up to 0.990 and specific AUROCs as high as 0.999 for ARVC detection.
Arrhythmogenic right ventricular cardiomyopathy (ARVC) and long QT syndrome (LQTS) are inherited arrhythmia syndromes associated with sudden cardiac death. Deep learning shows promise for ECG interpretation, but multi-class inherited arrhythmia classification with clinically grounded interpretability remains underdeveloped. Our objective was to develop and validate a lead-aware deep learning framework for multi-class (ARVC vs LQTS vs control) and binary inherited arrhythmia classification, and to determine optimal strategies for integrating ECG foundation models within arrhythmia screening tools. We assembled a 13-center Canadian cohort (645 patients; 1,344 ECGs). We evaluated four ECG foundation models using three transfer learning approaches: linear probing, fine-tuning, and combined strategies. We developed lead-aware spatial attention networks (LASAN) and assessed integration strategies combining LASAN with foundation models. Performance was compared against the established foundation model baselines. Lead-group masking quantified disease-specific lead dependence. Fine-tuning outperformed linear probing and combined strategies across all foundation models (mean macro-AUROC 0.904 vs 0.825). The best lead-aware integrations achieved near-ceiling performance (HuBERT-ECG hybrid: macro-AUROC 0.990; ARVC vs control AUROC 0.999; LQTS vs control AUROC 0.994). Lead masking demonstrated physiologic plausibility: V1-V3 were most critical for ARVC detection (4.54% AUROC reduction), while lateral leads were preferentially important for LQTS (2.60% drop). Lead-aware architectures achieved state-of-the-art performance for inherited arrhythmia classification, outperforming all existing published models on both binary and multi-class tasks while demonstrating clinically aligned lead dependence. These findings support potential utility for automated ECG screening pending validation.