Eur Heart J. 2026 Oct 30:ehag816. doi: 10.1093/eurheartj/ehag816. Online ahead of print.

ABSTRACT

External validation involving the testing of a frozen AI model on independent data from other sites, populations, time periods, or devices provides the clearest estimate of intended-use setting performance when those external data are deployment-representative of the expected population, measurement processes, and clinical workflow. It yields realistic estimates of discrimination and calibration, exposes shortcut learning and distribution shift, quantifies clinical utility through decision-analytic measures, and reveals subgroup disparities requiring mitigation. Yet common pitfalls undermine credibility: quasi-external splits with hidden relatedness; spectrum and prevalence mismatch; site, workflow, and hardware effects; label noise and reference-standard drift; analytic flexibility and selective reporting; small, underpowered samples; reliance only on the area under the curve; unreported threshold tuning; and leakage. A practical blueprint emphasizes pre-registration; representative, multi-site cohorts spanning geography, time, and acquisition; prevention of patient and temporal overlap; comprehensive evaluation of discrimination, calibration (including calibration-in-the-large, calibration slope, and calibration plots), and net benefit with confidence intervals; pre-specified subgroup and fairness audits; transparent labelling procedures and uncertainty analyses; principled sample-size calculations; and minimal, well-documented model updating (recalibration before revision). Finally, external validation should connect to post-deployment governance via drift detection, performance triggers, and change-control plans, complemented by site-specific local evaluation to ensure safety and reliability across diverse clinical environments. When executed to these standards, external validation transforms promising prototypes into dependable clinical tools, clarifying where a model performs, where it fails, and what adaptations are necessary for safe, equitable, and sustainable use. This framework links statistical evaluation to clinical use, model updating, and post-deployment monitoring.

PMID:42961821 | DOI:10.1093/eurheartj/ehag816