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Objective To discuss the feasibility of directly processing paper-based ECG by using deep learning method, and to propose a method for identifying atrial fibrillation ( AF) from paper-based ECG rapidly and accurately. Methods The 12-lead ECG signals of 1 040 AF and 1 344 non-AF patients were selected from CPSC 2018 Challenge data, and were plotted as ECGs. These ECGs were printed out on papers, and rescanned into images. The paper-based ECGs with white background were obtained by a series of preprocessing. These paper-based ECGs were used to construct AF recognition dataset; the artificial intelligence algorithm (AIA) was trained, validated and tested using the real labels provided by the Challenge as the gold standard. Results The sensitivity, specificity and F1 score of the AIA based on paper-based ECGs are 0. 957, 0. 978 and 0. 969, respectively, and the area under receiver operating characteristic curve is 0. 994. The Grad-CAM based feature visualization results show that in paper-based ECGs, the position of P wave and F wave at the onset of AF provide main references for the algorithm to identify AF, which is consistent with the ECG diagnostic criteria of AF in clinical practice. Conclusion The AF recognition algorithm based on paper-based ECGs shows good performance. The visualization results verify the high efficiency and feasibility of directly analyzing paper-based ECGs by using AIA, which could provide guidance for clinical practice. [ABSTRACT FROM AUTHOR]

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