Arrhythmias & electrophysiology
Accounting for inconclusive results and repeated testing: A framework for evaluating wearable electrocardiogram diagnostic performance with application to Apple Watch and artificial intelligence-enhanced interpretation
Authors' conclusion
Naive reporting inflates performance, whiereas pragmatic reporting deflates it. AI-enhanced interpretation materially reduces inconclusive results and improves ITD accuracy, providing a more usable and reliable pathway for real-world AF detection.
Study context
- Population
- Participants with Apple Watch electrocardiogram (ECG) recordings for atrial fibrillation (AF) detection at a teaching hospital in Irelandafter exclusions
- Participants
- 296 participants
- Comparison
- Apple Watch vs AI
- Outcome
- Wearable ECG diagnostic performance (sensitivity/specificity) in AF detection under naive (exclude inconclusive), pragmatic (count as incorrect) and ITD (permit 3 attempts) frameworks
Methodological detailsprospective, observational, single teaching hospital, Ireland
- Prospective
- Observational
- Single teaching hospital, Ireland
Performance
As reported in the abstract
Sensitivity/specificity for AF detection
| Test or model | Naive sensitivity/specificity | Pragmatic sensitivity/specificity | Intention-to-diagnose (ITD) sensitivity/specificity |
|---|---|---|---|
| Apple Watch | 96.1%/97.9% | 78.1%/81.0% | 92.2%/91.0% |
| AI | Not reported in the abstract | 98.4%/96.1% | 98.4%/96.6% |
Naive sensitivity/specificity
Apple Watch96.1%/97.9%
AINot reported in the abstract
Pragmatic sensitivity/specificity
Apple Watch78.1%/81.0%
AI98.4%/96.1%
Intention-to-diagnose (ITD) sensitivity/specificity
Apple Watch92.2%/91.0%
AI98.4%/96.6%
Further findings
Kappa
| Outcome | Apple Watch | AI | Reduction in inconclusive outputs |
|---|---|---|---|
| Inconclusive outputs | 92% | ||
| RepeatabilitySubstantial for Apple Watch, near-perfect for AI | 0.77 | 0.96 |
Original publication
Accounting for inconclusive results and repeated testing: A framework for evaluating wearable electrocardiogram diagnostic performance with application to Apple Watch and artificial intelligence-enhanced interpretation. Heart Rhythm. Published 7 November 2025. doi:10.
Summarised from the published abstract; every number is checked against it