ECG-SDI: Single-lead Electrocardiogram Enables Continuous Sleep Depth Index Profiling and Scalable Digital Biomarkers for Sleep Health

Overview & Synopsis

Conventional sleep staging provides a coarse-grained representation that obscures within-stage depth variation. We developed ECG-SDI, a single-lead electrocardiography (ECG) framework for continuous sleep-depth profiling and digital biomarker extraction. Using 12,392 overnight polysomnographic recordings, we trained and validated a two-stage deep learning model supervised by conventional sleep-stage labels. Correlations with ordered stages excluding rapid eye movement (REM) sleep were 0.828 in the pooled internal test set and 0.848 in the external Cleveland Family Study; corresponding REM classification AUROCs were 0.954 and 0.977. Overnight trajectories captured within-stage variation. Biomarker-based phenotyping identified a disturbed subtype associated with poorer subjective sleep quality and higher all-cause mortality in the Sleep Heart Health Study (adjusted hazard ratio, 1.20; 95% CI, 1.05-1.38). Among 507 participants with paired recordings before and after continuous positive airway pressure (CPAP), normalized sleep-depth area increased by 6.1% and shallow-sleep burden below 0.3 decreased by 16.0%. Exploratory analyses linked reductions in approximate entropy and depth variability to reduced oxygen desaturation and increased sleep efficiency, respectively (Spearman rho = 0.24 and 0.12); both associations remained positive after covariate adjustment. Mean ECG-SDI within N2 increased by 0.017 (95% CI, 0.004-0.030). A wearable proof-of-concept illustrated the acquisition-to-report workflow. These findings support ECG-based sleep phenotyping and further evaluation of CPAP response monitoring at home.