Chest pain symptoms are highly prevalent in emergency departments (EDs), where acute aortic syndrome (AAS) is a catastrophic cardiovascular emergency with a high fatality rate, especially when timely and accurate treatment is not administered. However, current triage practices in the ED can cause up to approximately half of patients with AAS to have an initially missed diagnosis or be misdiagnosed as having other acute chest pain conditions. Subsequently, these AAS patients will undergo clinically inaccurate or suboptimal differential diagnosis. Fortunately, even under these suboptimal protocols, nearly all these patients underwent non-contrast CT covering the aorta anatomy at the early stage of differential diagnosis. In this study, we developed an artificial intelligence model (DeepAAS) using non-contrast CT, which is highly accurate for identifying AAS and provides interpretable results to assist in clinical decision-making. Performance was assessed in two major phases: a multi-center retrospective study (n = 20,750) and an exploration in real-world emergency scenarios (n = 137,525). In the multi-center cohort, DeepAAS achieved a mean area under the receiver operating characteristic curve of 0.958 (95% CI 0.950-0.967). In the real-world cohort, DeepAAS detected 109 AAS patients with misguided initial suspicion, achieving 92.6% (95% CI 76.2%-97.5%) in mean sensitivity and 99.2% (95% CI 99.1%-99.3%) in mean specificity. Our AI model performed well on non-contrast CT at all applicable early stages of differential diagnosis workflows, effectively reduced the overall missed diagnosis and misdiagnosis rate from 48.8% to 4.8% and shortened the diagnosis time for patients with misguided initial suspicion from an average of 681.8 (74-11,820) mins to 68.5 (23-195) mins. DeepAAS could effectively fill the gap in the current clinical workflow without requiring additional tests.

Recent breakthroughs in large language models (LLMs) have led to their rapid dissemination and widespread use. One early application has been to medicine, where LLMs have been investigated to streamline clinical workflows and facilitate clinical analysis and decision-making. However, a leading barrier to the deployment of Artificial Intelligence (AI) and in particular LLMs has been concern for embedded gender and racial biases. Here, we evaluate whether a leading LLM, ChatGPT 3.5, exhibits gender and racial bias in clinical management of acute coronary syndrome (ACS). We find that specifying patients as female, African American, or Hispanic resulted in a decrease in guideline recommended medical management, diagnosis, and symptom management of ACS. Most notably, the largest disparities were seen in the recommendation of coronary angiography or stress testing for the diagnosis and further intervention of ACS and recommendation of high intensity statins. These disparities correlate with biases that have been observed clinically and have been implicated in the differential gender and racial morbidity and mortality outcomes of ACS and coronary artery disease. Furthermore, we find that the largest disparities are seen during unstable angina, where fewer explicit clinical guidelines exist. Finally, we find that through asking ChatGPT 3.5 to explain its reasoning prior to providing an answer, we are able to improve clinical accuracy and mitigate instances of gender and racial biases. This is among the first studies to demonstrate that the gender and racial biases that LLMs exhibit do in fact affect clinical management. Additionally, we demonstrate that existing strategies that improve LLM performance not only improve LLM performance in clinical management, but can also be used to mitigate gender and racial biases.

Even though the field of Artificial Intelligence is more than sixty years old, it is only in the last decade or so that AI systems are being increasingly interwoven into the fabric of the socio-technical apparatus of the society and are thus having a massive impact on society. This increasing incorporation of AI has led to increased calls for accountability and regulation of AI systems [8]. Model explanations are considered to be one of the most important ways to provide accountability of AI systems. The model explanations, however, can only be as good as the data on which the algorithms are based. This is where the issue of missing and imputed data becomes pivotal for model explanations. In some domains like healthcare, almost all datasets have missing values [6]. As many applications of AI in healthcare are patient-oriented, decisions that are informed by AI and ML models can potentially have significant clinical consequences.