Artificial Intelligence-Enabled Electrocardiography for Monitoring Serum Potassium Dynamics in Patients With Severe Hypokalemia.

RATIONALE & OBJECTIVE: Severe hypokalemia requires prompt management and close surveillance. Although artificial intelligence-enabled electrocardiography (AI-ECG) rapidly detects severe hypokalemia, its application for monitoring serum potassium (K+) dynamics during treatment remains unexplored. This study assessed AI-ECG performance in monitoring K+ changes during supplementation. STUDY DESIGN: Multicenter retrospective cohort study. SETTING & PARTICIPANTS: 191 adults with severe hypokalemia (Lab-K+ ≤2.5 mmol/L; matched ECG-K+ <3.5 mmol/L) and ≥1 follow-up paired measurement within 24 hours of K+ supplementation at three teaching hospitals between September 2019 and August 2024. TESTS COMPARED: Laboratory-measured K+ (Lab-K+) and K+ estimated by ECG (ECG-K+) overall and stratified by the etiology of hypokalemia (acute K+ shift vs. chronic K+ deficit). OUTCOMES: Primary: agreement between paired ECG-K+ and Lab-K+. Secondary: diagnostic accuracy and K+ trajectories. ANALYTICAL APPROACH: Linear mixed-effects models with patient-level random intercepts; repeated-measures correlation (rmcorr) and Bland-Altman plots; patient-level clustered bootstrapped ROC analysis for diagnostic accuracy. RESULTS: Of 191 patients, 156 (81.7%) had chronic K+ deficits (most commonly gastrointestinal disorders [n=47] or diuretic use [n=35]), and 35 (18.3%) had acute K+ shifts (most commonly thyrotoxic periodic paralysis [n=25]). The chronic K+ deficits group had more comorbidities and use of medications affecting K+. ECG-K+ correlated strongly with Lab-K+ (rmcorr 0.847; 95% CI, 0.81-0.88; p<0.001). The relationship was modified by hypokalemia etiology (interaction p<0.0001) with a lower correlation in patients with chronic K+ deficits. The diagnostic accuracy of ECG-K+ with Lab-K+ ≤3.5 mmol/L was reflected by an AUC of 0.920; 95% CI, 0.863-0.961. It was higher in patients with acute K+ shift. ECG-K+ preceded Lab-K+ results by a mean of 52.5 minutes. Patients with acute K+ shift corrected approximately threefold faster than those with chronic K+ deficit (0.121 vs. 0.039 mmol/L/h). Rebound hyperkalemia was detected by ECG-K+ in two patients before laboratory confirmation. LIMITATIONS: Retrospective design; treatment-protocol heterogeneity; limited inpatient medication granularity and potential selection bias. CONCLUSIONS: AI-ECG enables real-time, within-patient monitoring of serum K+ dynamics during treatment for severe hypokalemia, with superior performance in the setting of acute hypokalemia due to K+ shift. As a non-invasive adjunct, AI-ECG may shorten time to detect changes in K+ and reduce the need for laboratory K+ measurements than exclusive reliance on Lab-K+ measurements. Confirmatory studies are warranted.