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Abstract AimsMyocardial infarction and heart failure are major cardiovascular diseases that affect millions of people in the USA with morbidity and mortality being highest among patients who develop cardiogenic shock. Early recognition of cardiogenic shock allows prompt implementation of treatment measures. Our objective is to develop a new dynamic risk score, called CShock, to improve early detection of cardiogenic shock in the cardiac intensive care unit (ICU). Methods and resultsWe developed and externally validated a deep learning-based risk stratification tool, called CShock, for patients admitted into the cardiac ICU with acute decompensated heart failure and/or myocardial infarction to predict the onset of cardiogenic shock. We prepared a cardiac ICU dataset using the Medical Information Mart for Intensive Care-III database by annotating with physician-adjudicated outcomes. This dataset which consisted of 1500 patients with 204 having cardiogenic/mixed shock was then used to train CShock. The features used to train the model for CShock included patient demographics, cardiac ICU admission diagnoses, routinely measured laboratory values and vital signs, and relevant features manually extracted from echocardiogram and left heart catheterization reports. We externally validated the risk model on the New York University (NYU) Langone Health cardiac ICU database which was also annotated with physician-adjudicated outcomes. The external validation cohort consisted of 131 patients with 25 patients experiencing cardiogenic/mixed shock. CShock achieved an area under the receiver operator characteristic curve (AUROC) of 0.821 (95% CI 0.792–0.850). CShock was externally validated in the more contemporary NYU cohort and achieved an AUROC of 0.800 (95% CI 0.717–0.884), demonstrating its generalizability in other cardiac ICUs. Having an elevated heart rate is most predictive of cardiogenic shock development based on Shapley values. The other top 10 predictors are having an admission diagnosis of myocardial infarction with ST-segment elevation, having an admission diagnosis of acute decompensated heart failure, Braden Scale, Glasgow Coma Scale, blood urea nitrogen, systolic blood pressure, serum chloride, serum sodium, and arterial blood pH. ConclusionThe novel CShock score has the potential to provide automated detection and early warning for cardiogenic shock and improve the outcomes for millions of patients who suffer from myocardial infarction and heart failure. 

Although Shapley values are theoretically appealing for explaining black-box models, they are costly to calculate and thus impractical in settings that involve large, high-dimensional models. To remedy this issue, we introduce FastSHAP, a new method for estimating Shapley values in a single forward pass using a learned explainer model. To enable efficient training without requiring ground truth Shapley values, we develop an approach to train FastSHAP via stochastic gradient descent using a weighted least squares objective function. In our experiments with tabular and image datasets, we compare FastSHAP to existing estimation approaches and f ind that it generates accurate explanations with an orders-of-magnitude speedup.