Abstract
The advent of artificial intelligence in cardiovascular imaging holds immense potential for earlier diagnoses, precision medicine, and improved disease management. However, the presence of sex-based disparities and strategies to mitigate biases in deep learning models for cardiac imaging remain understudied. In this study, we analyzed algorithmic bias in a foundation model that was pretrained on cardiac magnetic resonance imaging and radiology reports from multiple institutes and finetuned to estimate ejection fraction (EF) on the UK Biobank dataset. The model performed significantly worse in EF estimation for females than males in the diagnosis of reduced EF. Algorithmic fairness did not improve despite masking of protected attributes in radiology reports and data resampling, although explicit input of sex in model finetuning may improve EF estimation in some cases. The underdiagnosis of reduced EF among females holds critical implications for the exacerbation of existing sex-based disparities in cardiovascular health. We advise caution in the development of models for cardiovascular imaging to avoid such pitfalls.