Artificial Intelligence-Enabled Electrocardiography for Preoperatively Detecting Atrial Fibrillation and Mortality Risk in Patients with Sinus Rhythm

<b>Background:</b> Pre-existing atrial fibrillation (AF) and postoperative new-onset AF (NOAF) are independent perioperative risk factors associated with increased short-term mortality and adverse events. This study aimed to develop and validate an artificial intelligence (AI) model capable of detecting hidden AF, including both pre-existing AF and NOAF, from sinus rhythm electrocardiograms, to improve perioperative risks assessment. <b>Methods:</b> We trained and validated an AI model to detect hidden AF. Subsequent analysis confirmed the prognostic relevance of both pre-existing AF and NOAF in patients receiving non-cardiac surgery. The AI model was applied to patients without known AF to evaluate its predictive capability for NOAF and to stratify short-term clinical outcomes. <b>Results:</b> The AI model demonstrated an area under the receiver operating characteristic curve of 0.87 during the development phase for predicting AF. In an independent validation cohort, pre-existing AF and postoperative NOAF were significantly correlated with increased 30-day all-cause mortality. Patients without pre-existing AF who were classified as high-risk by the AI model had substantially higher 30-day all-cause mortality than their low-risk counterparts (HR 17.33, 95% CI 5.29-56.75). Furthermore, the model scores surpassed conventional clinical risk scores in predicting NOAF and 30-day all-cause mortality. <b>Conclusions:</b> This AI-based approach facilitated the accurate identification of patients with elevated perioperative AF-related risk. It will facilitate focused interventions that may enhance clinical outcomes.