# A Multimodal and Explainable Machine Learning Approach to Diagnosing Multi-Class Ejection Fraction from Electrocardiograms

arXiv: https://arxiv.org/abs/2604.25942 · HTML: https://mlsanity.com/paper/2604.25942/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 3 of its 11 references that are in the map.
- First posted on arXiv 17 Apr 2026.

## Builds on (most cited first, 3 of 3)

- [A Unified Approach to Interpreting Model Predictions](https://mlsanity.com/paper/1705.07874/) (2017)
- [Integrated multimodal artificial intelligence framework for healthcare applications](https://mlsanity.com/paper/2202.12998/) (2022)
- [AI for Regulatory Affairs: Balancing Accuracy, Interpretability, and Computational Cost in Medical Device Classification](https://mlsanity.com/paper/2505.18695/) (2025)

## Abstract (arXiv)

Left ventricular ejection fraction (LVEF) assessment depends on echocardiography, limiting access in primary care and resource-constrained settings. We developed a multimodal machine-learning framework that combines engineered 12-lead ECG timeseries features with structured EHR variables to classify LVEF into four clinically used strata: normal (>50%), mildly reduced (40-50%), moderately reduced (30-40%), and severely reduced (<30%). To support model explainability, we identified the most influential ECG and EHR features via SHAP attributions. Using retrospective data from Hartford HealthCare, we trained XGBoost models on 36,784 ECG-echocardiogram pairs from 30,952 outpatients and evaluated temporal generalizability on 19,966 ECGs from a subsequent period. The multimodal model achieved one-vs-rest AUROCs of 0.95 (severe), 0.92 (moderate), 0.82 (mild), and 0.91 (normal), outperforming ECG-only and EHR-only baselines, and maintained performance under temporal validation. This work supports ECG-based, multimodal LVEF stratification as a practical screening and triage aid to prioritize confirmatory imaging where resources are limited.