Real-Time Integration of an AI-Based ECG Interpretation System in the Emergency Department: A Pragmatic Alternating-Day Study of Diagnostic Performance and Clinical Process Metrics

Background/Objectives: Rapid and accurate electrocardiogram (ECG) interpretation is essential for timely recognition of ST-elevation myocardial infarction (STEMI) and initiation of reperfusion therapy in the emergency department (ED). We evaluated the diagnostic performance of a real-time artificial intelligence (AI) ECG interpretation system and its pragmatic impact when integrated into routine ED workflows. Methods: This prospective, single-center pragmatic observational study was conducted in a regional emergency medical center ED in Busan, Republic of Korea (1 January–31 December 2024). Consecutive adults (≥18 years) undergoing 12-lead ECG for cardiovascular-related symptoms were enrolled (N = 1524). A predefined alternating-day protocol allocated visits to physician-only interpretation days (physician-days, n = 763) or AI-output disclosure days (AI-days, n = 761). Diagnostic performance for STEMI was assessed using paired ECG-level comparisons between physician-alone interpretation and AI output against a blinded expert-panel reference standard; clinical impact outcomes included reperfusion-related time metrics, hospital length of stay (LOS), and in-hospital mortality. Results: Against the expert reference standard, AI showed higher STEMI sensitivity than physician-alone interpretation (96.7% vs. 68.3%; McNemar p = 0.027), while specificity was lower (75.9% vs. 84.5%; p = 0.018). In pragmatic day-level comparisons, door-to-balloon time was shorter on AI-days (40.0 ± 19.81 vs. 47.34 ± 21.90 min; p = 0.001), and time to PCI was significantly reduced among patients with atypical presentations (42.3 ± 18.21 vs. 57.1 ± 20.11 min; p = 0.013). Among admitted patients, hospital LOS was shorter on AI-days (13 ± 9.21 vs. 17 ± 10.31 days; p = 0.010), whereas in-hospital mortality did not differ significantly between groups (17.0% vs. 16.77%; p = 0.191). Conclusions: Real-time AI-ECG integration in the ED was associated with improved STEMI detection sensitivity and shorter reperfusion-related time metrics, particularly in atypical presentations, and with reduced hospital LOS among admitted patients. Short-term mortality was comparable between groups. Further multicenter studies are warranted to confirm generalizability and to balance benefits against potential false-positive–related operational impacts.