AI-Enhanced Electrocardiogram for Detection of Occlusive Myocardial Infarction in High-Risk Non–ST-Segment Elevation Acute Coronary Syndrome
Overview
This study evaluates an AI-enhanced ECG model for detecting occlusive myocardial infarction (OMI) in patients with high-risk non–ST-segment elevation acute coronary syndrome, using angiography as the reference. The model improved rule-in accuracy with high specificity (78%) and reduced false-positive cath lab activations compared with standard care, while rule-out sensitivity remained limited on the initial ECG. Serial ECG analysis improved detection, supporting the use of AI as a triage aid alongside clinical judgment rather than a standalone diagnostic tool.
Key findings
- Detects occlusion MI in high-risk NSTE-ACS, angiography as reference.
- 78% specificity improved rule-in and reduced false cath activations.
- Serial ECG analysis improved detection; best used as a triage aid.
Published in: JACC Advances
Published on: 25 March 2026
Background
Whether an artificial intelligence–enhanced electrocardiogram (AI-ECG) improves detection of occlusive myocardial infarction (OMI) in non–ST-segment elevation acute coronary syndrome (NSTE-ACS) compared with standard of care (SOC) remains uncertain.
Methods
Consecutive adults undergoing emergent ICA under the institutional level 2 protocol for suspected high-risk NSTE-ACS (2022-2024) were included. Patients with ST-elevation myocardial infarction were excluded. Initial 12-lead ECGs were retrospectively analyzed using an investigational AI-ECG model (Queen of Hearts, Powerful Medical) validated against ICA findings. OMI was defined as an angiographic culprit lesion with TIMI flow grade 0 to 2 or TIMI flow grade 3 with marked troponin elevation or new regional wall motion abnormality.
Results
Among 224 patients, OMI was present in 129 (58%). AI-ECG identified 75 (58%) of these as OMI and classified 96 patients (43%) as OMI overall. For rule in, specificity was 78% (95% CI: 68%-86%) and positive predictive value 78% (95% CI: 69%-86%). For rule out, sensitivity was 58% (95% CI: 49%-66%) and negative predictive value 57% (95% CI: 48%-66%). Serial ECGs reduced false negatives from 42% to 34%. Compared with the standard of care, an AI-augmented triage approach reduced false positives from 42% to 22% (P < 0.001).
Conclusion
In high-risk NSTE-ACS, AI-ECG improved rule in accuracy for OMI, potentially enhancing early identification of patients requiring urgent ICA. However, rule out performance from initial ECG alone was limited, supporting the need for serial ECGs and clinical judgment.
Authors: Pedro E.P. Carvalho MD, Will Belzer BA, Daniel L. Pollmann MD, Hans C. Helseth BA, Jay H. Traverse MD, Robert Herman MD, PhD, Deniz Mutlu MD, Anil Poulose MD, Michael Mooney MD, M. Nicholas Burke MD, Konstantinos Voudris MD, PhD, Mario Goessl MD, PhD,Ivan Chavez MD, YaleL. Wang MD, Dimitrios Strepkos MD, Michaella Alexandrou MD, Ellen Cravero MS, Bavana V. Rangan BDS, MPH, Allan S. Jaffe MD, Emmanouil S. Brilakis MD, PhD, Yader Sandoval MD
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About PMcardio
PMcardio is the market leader in AI-powered diagnostics, addressing the world’s leading cause of death – cardiovascular diseases. The innovative clinical assistant empowers healthcare professionals to detect up to 40 cardiovascular diseases. In the form of a smartphone application, the certified Class IIb medical device interprets any 12-lead ECG image in under 5 seconds to provide accurate diagnoses and individualized treatment recommendations tailored to each patient.
About Powerful Medical
Powerful Medical leads one of the most important shifts in modern medicine by augmenting human-made clinical decisions with artificial intelligence. Our primary focus is on cardiovascular diseases, the world’s leading cause of death.
Established in 2017, Powerful Medical has embarked on a mission to revolutionize the diagnosis and treatment of cardiovascular diseases. We are a medical company backed by 28 world-class cardiologists and led by our expert Scientific Board with decades of experience in daily patient care, clinical research, and medical devices. The results of our research are implemented, developed, certified, and brought to market by our 50+ strong interdisciplinary team of physicians, data scientists, AI experts, software engineers, regulatory specialists, and commercial teams.
