Machine learning to predict the long-term risk of myocardial infarction and cardiac death based on clinical risk, coronary calcium, and epicardial adipose tissue: a prospective study

Cardiovasc Res. 2020 Dec 1;116(14):2216-2225. doi: 10.1093/cvr/cvz321.


Aims: Our aim was to evaluate the performance of machine learning (ML), integrating clinical parameters with coronary artery calcium (CAC), and automated epicardial adipose tissue (EAT) quantification, for the prediction of long-term risk of myocardial infarction (MI) and cardiac death in asymptomatic subjects.

Methods and results: Our study included 1912 asymptomatic subjects [1117 (58.4%) male, age: 55.8 ± 9.1 years] from the prospective EISNER trial with long-term follow-up after CAC scoring. EAT volume and density were quantified using a fully automated deep learning method. ML extreme gradient boosting was trained using clinical co-variates, plasma lipid panel measurements, risk factors, CAC, aortic calcium, and automated EAT measures, and validated using repeated 10-fold cross validation. During mean follow-up of 14.5 ± 2 years, 76 events of MI and/or cardiac death occurred. ML obtained a significantly higher AUC than atherosclerotic cardiovascular disease (ASCVD) risk and CAC score for predicting events (ML: 0.82; ASCVD: 0.77; CAC: 0.77, P < 0.05 for all). Subjects with a higher ML score (by Youden's index) had high hazard of suffering events (HR: 10.38, P < 0.001); the relationships persisted in multivariable analysis including ASCVD-risk and CAC measures (HR: 2.94, P = 0.005). Age, ASCVD-risk, and CAC were prognostically important for both genders. Systolic blood pressure was more important than cholesterol in women, and the opposite in men.

Conclusions: In this prospective study, machine learning used to integrate clinical and quantitative imaging-based variables significantly improves prediction of MI and cardiac death compared with standard clinical risk assessment. Following further validation, such a personalized paradigm could potentially be used to improve cardiovascular risk assessment.

Keywords: Coronary calcium scoring; Epicardial adipose tissue; Machine learning; Myocardial infarction and cardiac death.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adipose Tissue / diagnostic imaging*
  • Aged
  • Cause of Death
  • Computed Tomography Angiography*
  • Coronary Angiography*
  • Coronary Artery Disease / complications
  • Coronary Artery Disease / diagnostic imaging*
  • Coronary Artery Disease / mortality
  • Coronary Artery Disease / physiopathology
  • Decision Support Techniques
  • Female
  • Humans
  • Machine Learning*
  • Male
  • Middle Aged
  • Multidetector Computed Tomography*
  • Myocardial Infarction / etiology*
  • Myocardial Infarction / mortality
  • Myocardial Infarction / physiopathology
  • Pericardium
  • Predictive Value of Tests
  • Prognosis
  • Prospective Studies
  • Radiographic Image Interpretation, Computer-Assisted*
  • Risk Assessment
  • Risk Factors
  • Sex Factors
  • Time Factors
  • Vascular Calcification / complications
  • Vascular Calcification / diagnostic imaging*
  • Vascular Calcification / mortality
  • Vascular Calcification / physiopathology