Image-based deep learning for emergency electrocardiogram classification

Automated electrocardiogram analysis has advanced largely through digital waveforms, yet many emergency-care workflows rely on ECGs available only as printed tracings, scanned reports, PDFs or mobile photographs. We developed an image-based deep learning system for emergency ECG classification and evaluated it in InCor-EMG, an expert-adjudicated dataset of 18,519 emergency ECGs spanning 12 ECG categories, with labels from 19 cardiologists. On the held-out test set, the final ConvNeXt ensemble achieved a macro F1-score of 0.807 (95% CI, 0.788-0.825), compared with 0.820 (95% CI, 0.805-0.832) for annotating cardiologists, and higher F1-scores than Mortara Veritas in most evaluated categories. Performance was associated more strongly with inter-reader agreement than with training sample size and remained informative across scanned and photographed ECGs, with supportive performance in model-enriched temporal and heterogeneous public-image evaluations. These findings support ECG image classification when digital waveforms are unavailable.