Slow-fast or typical atrioventricular nodal reentrant tachycardia (AVNRT) is the most common cause of paroxysmal supraventricular tachycardia (SVT). A surface electrocardiogram (ECG) V1 RP interval of less than or equal...Slow-fast or typical atrioventricular nodal reentrant tachycardia (AVNRT) is the most common cause of paroxysmal supraventricular tachycardia (SVT). A surface electrocardiogram (ECG) V1 RP interval of less than or equal to 90 ms has been cited as an upper cut-off for maximum RP observed in AVNRT. This criterion was defined using ventriculoatrial (VA) time measured from intracardiac electrograms (EGMs), namely the interval from the onset of QRS to the rapid deflection of the atrial electrogram at the high right atrial (HRA) electrode. Specifically, this was considered at the limit of the shortest one can observe in atrioventricular reentrant tachycardia (AVRT), hence indicating a diagnosis of AVNRT. In this study, we analyzed surface ECGs during tachycardia onset from 200 electrophysiology study (EPS)-confirmed cases of SVT, of which 142 (71 %) were diagnosed as AVNRT. We report that an RP interval ≤ 90 ms demonstrated improved diagnostic performance over ≤70 ms cutoff (≤90 ms: sensitivity of 97.2 % [95 % CI: 93.0-99.2] and specificity of 96.6 % [95 % CI: 88.1-99.6]; ≤70 ms: sensitivity 81.7 % [95 % CI: 74.3-87.7], specificity 98.3 % [95 % CI: 90.8-99.9]). Using a 90 ms RP threshold would reduce the false negative rate from 13 % to 2 %, potentially improving the accuracy of surface ECG-based SVT diagnosis. Overall, our findings support the use of ECG V1 RP ≤ 90 ms cutoff as a diagnostic marker of typical AVNRT.
Rapid atrioventricular nodal non-reentrant tachycardia (DAVNNT) with intraventricular differential conduction-induced wide QRS tachycardia (WCT) is often misdiagnosed as ventricular tachycardia (VT) due to its distinctiv...Rapid atrioventricular nodal non-reentrant tachycardia (DAVNNT) with intraventricular differential conduction-induced wide QRS tachycardia (WCT) is often misdiagnosed as ventricular tachycardia (VT) due to its distinctive atrioventricular conduction characteristics, making timely and accurate diagnosis and treatment challenging. This case report describes a 42-year-old female patient who presented with recurrent palpitations, with a dynamic electrocardiogram documenting a WCT that mimicked VT. Esophageal electrophysiological studies revealed a 1:2 atrioventricular conduction pattern. Intracardiac electrophysiological examination confirmed the diagnosis of DAVNNT, which was successfully treated with radiofrequency ablation. This case highlights that WCT with fewer P waves than QRS complexes can occur in DAVNNT, similar to VT. By logical inference a 1:2 atrioventricular conduction pattern, together with suspected interpolated ventricular or junctional premature contractions exhibiting variable QRS morphology, may serve as key diagnostic clues for DAVNNT.
The U wave is a deflection of the electrocardiogram whose genesis and clinical significance are yet unclear. It usually appears at the end of each ventricular complex in a selected lead. This study presents a unique case...The U wave is a deflection of the electrocardiogram whose genesis and clinical significance are yet unclear. It usually appears at the end of each ventricular complex in a selected lead. This study presents a unique case where the U wave appeared exclusively in beat-to-beat alternating cardiac cycles, so as to give rise to a pattern of " bigeminal U wave". Moreover, the presence of the U wave appeared to be related to the previous duration of the cardiac cycle correlating with lengthening of the cardiac cycle, while it did occur after shortening of the cardiac cycle. We can hypothesize that prolonged action potentials in ventricular M cells might contribute to this phenomenon.
OBJECTIVES: To evaluate the diagnostic accuracy of electrocardiographic (ECG) criteria for detecting left atrial (LA) and left ventricular (LV) disease in pediatric patients using age-specific analysis. STUDY DESIGN: Thi...OBJECTIVES: To evaluate the diagnostic accuracy of electrocardiographic (ECG) criteria for detecting left atrial (LA) and left ventricular (LV) disease in pediatric patients using age-specific analysis. STUDY DESIGN: This retrospective case-control study, part of the CHILDHEART Project, included pediatric patients aged 0 to 14 years diagnosed with LA disease (n = 152) or LV disease (n = 213), along with control groups (LA controls n = 1485; LV controls n = 1424). ECGs were evaluated for traditional and novel criteria. Participants were stratified into two age groups: under 3 years and 3 years or older. Sensitivity, specificity, likelihood ratios, and receiver operating characteristic (ROC) curves were calculated to assess diagnostic performance. RESULTS: Traditional ECG criteria for LA hypertrophy, such as the Morris sign, demonstrated limited diagnostic accuracy, showing low sensitivity and specificity across both age groups. A P wave amplitude in lead II ≥2.5 mm cannot accurately distinguish right atrial diseases from LA hypertrophy. For LV hypertrophy, the Modified Peguero-Lo Presti index (SV3 + SV4) yielded an LR+ of 11.88 in children <3 years (cutoff ≥35 mm) and 11.36 in those ≥3 years (cutoff ≥49 mm). A new index (RI + RV6) performed consistently across both age groups, with an LR+ of 21.32 for <3 years and 7.87 for ≥3 years using a fixed cutoff of ≥37 mm. Both indices had limited utility in ruling out disease due to low LR- values. CONCLUSIONS: Standard ECG criteria may not be adequate for diagnosing LA and LV disease in pediatric patients. The RI + RV6 index, using a single cutoff across ages, and age-stratified thresholds for the Modified Peguero-Lo Presti index may improve diagnostic accuracy.
BACKGROUND: Drug challenge is useful to identify patients with Brugada syndrome (BS) without spontaneous ECG type 1 pattern. Effect of class I antiarrhythmic challenge is difficult to anticipate and potentially associate...BACKGROUND: Drug challenge is useful to identify patients with Brugada syndrome (BS) without spontaneous ECG type 1 pattern. Effect of class I antiarrhythmic challenge is difficult to anticipate and potentially associated with complications. OBJECTIVE: Assess the response to class I antiarrhythmic challenge. METHODS: We included patients from the French multicenter MUTAVIT registry with a drug induced BS. Using digitized ECG, we automatically quantified 12‑lead ECG parameters on lead V1-V3. RESULTS: Among 157 patients (72 % males, mean age 43 ± 13 years), baseline ECG did not show a type 2 or 3 BS pattern in 58 %. Drug infusion induced a QRS prolongation from 96 ± 20 to 117 ± 25 ms and an increase of ST amplitude from 107 ± 82 to 345 ± 231 μV (lead V2). Amplitude of drug-challenge effect was associated with homogeneous response across groups (with and without baseline BS pattern). Baseline ST elevation correlated with a pronounced response to the induction test (on V1: r = 0.697 (0.568; 0.792), p < 0.001, R = 0.486). Conversely, on-drug QRS duration was poorly correlated with baseline QRS duration (on V2: r = 0.215 (0.0527; 0.366), p < 0.05, R = 0.046). SCN5A variant carriers had longer QRS duration at baseline but not during drug challenge. Male patients had prolonged baseline QRS and baseline and post-induction ST amplitude. CONCLUSION: Amplitude of sodium blockade effect on ST elevation was correlated with baseline ST amplitude but dugs effect on QRS duration was only slightly correlated with baseline QRS duration. Presence of (likely) pathogenic SCN5A variant was associated with different baseline ECG characteristics and response to sodium channel blockade.
The painful left bundle branch block (LBBB) syndrome, a rare and often underdiagnosed condition, remains a significant challenge in clinical cardiology. In this case report, we present a 74-year-old female patient who ex...The painful left bundle branch block (LBBB) syndrome, a rare and often underdiagnosed condition, remains a significant challenge in clinical cardiology. In this case report, we present a 74-year-old female patient who exhibited classic features of rate-dependent LBBB accompanied by angina pectoris. Intriguingly, comprehensive diagnostic evaluations revealed no evidence of obstructive coronary artery disease, highlighting the complex pathophysiology underlying this unique clinical presentation.
BACKGROUND: The rapid global adoption of electronic cigarettes (e-cigarettes) has sparked concerns about their cardiovascular safety, particularly their impact on ventricular repolarization - a critical electrophysiologi...BACKGROUND: The rapid global adoption of electronic cigarettes (e-cigarettes) has sparked concerns about their cardiovascular safety, particularly their impact on ventricular repolarization - a critical electrophysiological process linked to arrhythmia risk. Despite growing usage, evidence on how e-cigarettes affect ECG-derived repolarization parameters remains fragmented and insufficiently explored, highlighting a pressing need for synthesis. METHODS: This systematic review and meta-analysis focused exclusively on e-cigarette users, evaluating four ventricular repolarization markers: Tpe/QT ratio, Tp-e/QTc ratio, QT interval (ms), and Tp-e interval (ms). Databases (PubMed, Embase, Cochrane, Scopus, Web of Science) were systematically searched for human studies comparing e-cigarette users to non-smokers. Inclusion criteria mandated clear reporting of at least one repolarization parameter and distinct groups (e-cigarette users vs. non-smokers). Studies from various regions worldwide were included, ensuring broad geographic diversity and a comprehensive analysis of different healthcare systems and populations. Studies with mixed populations (e.g., combined tobacco/e-cigarette users) or marijuana consumers were excluded. No biases were detected after thorough evaluation. RESULTS: 254 patients were included (114 e-cigarette users, 140 controls) from 3 studies. Pooled analyses using random-effects models demonstrated significant adverse effects of e-cigarette use across all parameters. Tp-e/QTc ratio exhibited the strongest association, with a standardized mean difference (SMD) of 1.04 [95 % CI: 0.78-1.31; p < 0.00001], indicating pronounced prolongation in e-cigarette users. Notably, this finding showed remarkable consistency (I = 0 %), suggesting minimal heterogeneity between studies. For the Tpe/QT ratio, the SMD was 0.81 [0.17-1.46; p = 0.01], though high heterogeneity (I = 83 %) urged caution in interpretation. The QT interval was prolonged by 8.36 ms [2.44-14.29; p = 0.006], while the Tp-e interval increased by 4.34 ms [1.56-7.12; p < 0.00001], both statistically robust outcomes. Sensitivity analyses and subgroup tests confirmed reliability, with Wald-type confidence intervals and restricted maximum-likelihood (Tau) methods addressing variability. CONCLUSION: E-cigarette use is associated with significant alterations in ventricular repolarization parameters, suggesting potential arrhythmogenic risks. While the results are statistically robust, the meta-analysis included few high-quality studies, reflecting a critical gap in the current evidence base. To confirm these findings and elucidate long-term cardiovascular effects, rigorously designed, large-scale studies are urgently needed. Future research must prioritize standardized methodologies and longitudinal assessments to ensure clinical relevance and reliability.
INTRODUCTION: QRS morphology and duration (QRS) impact electrical dyssynchrony and the likelihood of response to cardiac resynchronization therapy (CRT). METHODS: Four groups of heart failure patients (n = 181) with CRT...INTRODUCTION: QRS morphology and duration (QRS) impact electrical dyssynchrony and the likelihood of response to cardiac resynchronization therapy (CRT). METHODS: Four groups of heart failure patients (n = 181) with CRT and left ventricular conduction delay were studied: Strauss left bundle branch block (Strauss LBBB; n = 73), LBBB not meeting Strauss criteria (non-Strauss LBBB; n = 29), interventricular conduction delay (IVCD; n = 54), and right ventricular pacing (RVp; n = 25). Electrical dyssynchrony was measured (using a novel proprietary technology) as systolic area under the curve (AUC) of multiple paired anterior and posterior electrocardiograms. LV electrical resynchronization was defined as the percent change in AUC during pacing, compared to native conduction (cardiac resynchronization index; CRI). RESULTS: Native rhythm AUC was significantly (p < 0.01) more negative (greater dyssynchrony) in the Strauss LBBB and RVp groups than in the non-Strauss LBBB and IVCD groups. Native rhythm AUC (absolute value) increased significantly as QRS increased in all groups except RVp. Although native AUC differed between groups, no between-group differences were found in post-CRT baseline AUC (-35 ± 39 mV*ms), baseline CRI (57 ± 29 %), optimally programmed AUC (-3 ± 13 mV*ms) or optimally programmed CRI (90 ± 12 %). Electrical dyssynchrony maps plotting CRI at multiple different AVDs and VVDs showed similar patterns of wavefront fusion across all 4 patient groups. CONCLUSION: Electrical dyssynchrony varies significantly with QRS morphology during native conduction, but not during CRT pacing at baseline or optimal settings. Regardless of QRS duration or morphology, patients with LV activation delay demonstrate similar and large improvements in electrical synchrony with optimized CRT.
Currently, there is a lack of convenient and effective methods for assessing recurrent angina following percutaneous coronary intervention (PCI). We documented the course of magnetocardiography's (MCG) changes in a 41-ye...Currently, there is a lack of convenient and effective methods for assessing recurrent angina following percutaneous coronary intervention (PCI). We documented the course of magnetocardiography's (MCG) changes in a 41-year-old man with recurrent angina throughout his visit to the clinic. The MCG suggested myocardial ischemia at the first visit. After revascularization with subtotal occlusion of the first diagonal branch (D1), the MCG returned to normal. However, due to his refusal of stent implantation, the angina recurred after one month. The MCG showed myocardial ischemia again, with a normal electrocardiogram (ECG) and cardiac troponin I (cTNI). This raised suspicions of D1 restenosis, a hypothesis that was confirmed by a second coronary angiography (CAG) later. A stent was successfully implanted this time and the patient has been followed up without angina recurrence till date. This case indicates that MCG has good potential to improve the diagnostic pathway especially in recurrent angina with normal ECG and cardiac biomarkers.
BACKGROUND: Cardiovascular disease remains the leading cause of morbidity and mortality in kidney transplant (KT) recipients. Although electrocardiograms (ECGs) are commonly included in pre-transplant evaluations, their...BACKGROUND: Cardiovascular disease remains the leading cause of morbidity and mortality in kidney transplant (KT) recipients. Although electrocardiograms (ECGs) are commonly included in pre-transplant evaluations, their association with post-transplant cardiovascular outcomes has not been well studied. METHODS: We conducted a single-center retrospective chart review of KT recipients over a 10-year period. Charts were reviewed for baseline demographics, comorbidities, laboratory findings, medications as well as post-transplant outcomes. ECGs were independently reviewed for abnormalities. The primary outcome was the occurrence of major adverse cardiovascular events (MACE), defined as cardiovascular death, non-fatal acute coronary syndrome, cerebrovascular accident, hospitalizations for heart failure, coronary revascularization or major arrhythmias. A Cox Proportional Hazard Regression model was constructed adjusting for confounding factors identified from univariate logistic regression. RESULTS: Of 522 KT recipients at our institution, 503 had a baseline acceptable-quality ECG. Over a mean follow-up of 54 ± 30 months, 99 (19.7 %) patients experienced a MACE event. In the multivariable model, first-degree atrioventricular (AV) block (HR: 2.35, 95 % CI: 1.36-4.05, p < 0.01) and ST-segment depression (HR: 3.40, 95 % CI: 1.59-7.29, p < 0.01) were independently associated with MACE. Stratified analysis showed that first-degree AV block was predictive of MACE in both CAD+ and CAD- patients, while ST-segment depression was only significant in the CAD+ subgroup. Interaction analysis revealed a significant interaction between T-wave inversion and CAD (HR: 0.33, 95 % CI: 0.12-0.93, p = 0.04). CONCLUSIONS: In this large retrospective study of KT recipients, first-degree AV block was independently associated with increased risk of MACE after KT. ST-segment depression was also significantly associated with MACE, especially in the subgroup of patients with CAD. Further studies are needed to evaluate the value of adding these variables to pre-transplant risk stratification models.
OBJECTIVE: To evaluate age-specific electrocardiographic (ECG) criteria to improve the diagnosis of right ventricular disease (RVD) in pediatric patients. STUDY DESIGN: This retrospective case-control study included 246...OBJECTIVE: To evaluate age-specific electrocardiographic (ECG) criteria to improve the diagnosis of right ventricular disease (RVD) in pediatric patients. STUDY DESIGN: This retrospective case-control study included 246 pediatric patients aged 0 to 14 years with confirmed RVD and 1391 age-matched controls without RVD. ECGs were analyzed to identify relevant criteria, including RV1 amplitude, SV6 amplitude, combined RV1 + SV6 amplitude, right bundle branch block (RBBB), and others. Multivariate logistic regression was used to develop the CHILDHEART diagnostic score, which was internally validated using bootstrap methods. RESULTS: The CHILDHEART score demonstrated strong diagnostic accuracy for RVD across all age groups. In children under 3 years, the score achieved an area under the curve (AUC) of 0.84, with a positive likelihood ratio (LR+) of 15.97 for scores of 2 or more, indicating high specificity. In children aged 3 years or older, the AUC was 0.81, and the LR+ was 35.77 for scores of 2 or more, emphasizing its clinical utility. Significant predictors included RBBB and RV1 + SV6 ≥ 18 mm. CONCLUSIONS: The CHILDHEART score is a reliable tool for diagnosing RVD in pediatric patients, offering robust diagnostic accuracy across different age groups. Its implementation could enhance clinical decision-making and improve patient outcomes. Limitations include the retrospective design and potential selection bias, underscoring the need for prospective studies to further validate these findings.
Gupta A, Harvey CJ, Mahmood U
… +8 more, Baer J, Parimi N, Bapat A, Sheldon SH, Reddy M, Yao Z, Lee Y, Noheria A
J Electrocardiol
· 2025 · PMID 40716195
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BACKGROUND: Vectorcardiographic 3D QRS voltage-time integral (VTI) is a novel marker of ventricular dyssynchrony pertinent for cardiac resynchronization therapy. It may have additional clinical utility but its normal ref...BACKGROUND: Vectorcardiographic 3D QRS voltage-time integral (VTI) is a novel marker of ventricular dyssynchrony pertinent for cardiac resynchronization therapy. It may have additional clinical utility but its normal reference ranges have not been established. We sought to define reference ranges for VTI in healthy individuals. METHODS: We retrospectively analyzed 12‑lead ECGs of healthy adults (2010-2014) and compared them to patients with cardiomyopathy with reduced ejection fraction (EF) <50 %. Using the Kors matrix, 12‑lead ECGs with QRS duration ≤120 ms were converted to vectorcardiographic X, Y, and Z leads. VTI was calculated as the instantaneous root-mean-square (3D) voltage integrated over the QRS duration. Reference range limits were defined as the 2.5th to 97.5th percentiles respectively for healthy females and males in age groups 18-34, 35-54 and ≥ 55 years. RESULTS: The study included 468 healthy adults (age 44.6 ± 17.0 years; 63.9 % female) and 314 patients with cardiomyopathy (age 62.1 ± 14.0 years; 34.4 % female). VTI was significantly larger in the cardiomyopathy patients compared to the healthy population (48.2 ± 21.4 vs. 38.1 ± 9.3 μVs, p < 0.0001). Increased age and female sex were significant predictors of lower VTI in the healthy population (both p < 0.0001). VTI reference ranges for respective age groups for healthy females were 23.2-55.0, 23.9-56.4 and 19.6-50.9 μVs, and for healthy males were 29.9-57.2, 28.2-56.7 and 21.4-55.9 μVs. CONCLUSION: VTI is higher in younger individuals and males within healthy adult population but is overall higher in patients with cardiomyopathy with reduced EF. Age and sex need to be accounted for using VTI as a marker for cardiac disease.
BACKGROUND: The discrepancy between cardiac age, estimated from electrocardiograms (ECGs), and chronological age can serve as an indicator of cardiovascular health. A significant difference may reflect vascular aging and...BACKGROUND: The discrepancy between cardiac age, estimated from electrocardiograms (ECGs), and chronological age can serve as an indicator of cardiovascular health. A significant difference may reflect vascular aging and elevated risk, but improving the precision and interpretability of these predictions remains challenging. METHODS: This study proposes novel preprocessing techniques to improve prediction accuracy and investigates the relationship between lifestyle factors and cardiac aging. ECG signals were processed using a Butterworth bandpass filter combined with a Hyperbolic Tangent transformation. A loss-tolerant training mechanism was introduced to reduce the impact of label noise. The model was trained on the PTB-XL dataset, and lifestyle-related analyses were conducted using the PLHDB and AISDB databases, which include both ECG recordings and behavioural information. RESULTS: The proposed model achieved a mean absolute error (MAE) of 6.76 years on the PTB-XL dataset, outperforming existing approaches under comparable conditions. Lifestyle analysis revealed that regular exercise was associated with a 1.31-year reduction in predicted cardiac age, while smoking and excessive alcohol intake were associated with increases of 3.67 and 1.22 years, respectively. CONCLUSIONS: These findings demonstrate the utility of ECG-based deep learning models not only for precise cardiac age estimation but also for elucidating the effects of lifestyle behaviours on cardiovascular health.
BACKGROUND: The atria are complex structures that are still not completely understood. Characterization of atrial bundles has been done in diseased hearts, magnetic resonance tractography, and computational models. To da...BACKGROUND: The atria are complex structures that are still not completely understood. Characterization of atrial bundles has been done in diseased hearts, magnetic resonance tractography, and computational models. To date, no technique has been able to map and characterize endo-epicardial fibers using a standard mapping catheter. The primary purpose of this study was to assess the informational content of far-field electrograms recorded in the left atrium during sinus rhythm. METHODS: We included patients who underwent left atrial mapping for atrial fibrillation ablation. A conventional HD-Grid™ catheter was used to perform electro-anatomical mapping of the left atrium, strictly during sinus rhythm and in non-diseased atria. Software programming was used to display additional electrograms selected from electrode pairs at increased inter-electrode distance along the mapping catheter. Four configurations of high density electrograms of varying inter-electrode distances were generated and analyzed. RESULTS: We included 22 patients in the study. The mean age was 50 years, and the mean atrial volume was 30.4 ml/m2. We found two main patterns of left atrial activation. 70 % of patients had a type 1 pattern, where activation initiated in the Bachman's bundle- corresponding region, and type two pattern, where activation started in the septo-atrial bundle-corresponding region. When we increased the interspaced in the electrodes of the mapping catheter, areas of far-field activation were detected and when we compared them to the prior descriptions of tracts and bundles, they seemed to correspond to epicardial activation. CONCLUSIONS: We introduce a new technique of confocal mapping that allows for the assessment of endo-epicardial activation and aids in the understanding of the complex atrial structure.
PURPOSE: To examine the associations between P wave, QT interval, and corrected QT interval dispersion and clinical pathologies in multisystem inflammatory syndrome in children (MIS-C). METHODS: This study included 60 ch...PURPOSE: To examine the associations between P wave, QT interval, and corrected QT interval dispersion and clinical pathologies in multisystem inflammatory syndrome in children (MIS-C). METHODS: This study included 60 children diagnosed with MIS-C according to the US Centers for Disease Control and Prevention criteria and 26 healthy children. Their maximum and minimum P wave durations and QT interval durations were measured by 12‑lead surface electrocardiography. RESULTS: P wave and QT interval dispersion were significantly greater in the children with MIS-C than in the healthy children (p < 0.001). In addition, P wave and QT interval dispersion were significantly greater before than after treatment among the children with MIS-C (p < 0.001). CONCLUSIONS: Our study found significantly greater P wave dispersion and QT dispersion in the patient group than in the control group. This correlates with the frequency of arrhythmias seen in MIS-C. We suggest that patients hospitalized with MIS-C should be meticulously monitored for potential arrhythmias.
OBJECTIVE: To evaluate the impact of age, sex and hypertension to improve ECG diagnosis of Left Ventricular Hypertrophy (LVH). METHODS: The study evaluated 14 different QRS voltage criteria as well as our recently propos...OBJECTIVE: To evaluate the impact of age, sex and hypertension to improve ECG diagnosis of Left Ventricular Hypertrophy (LVH). METHODS: The study evaluated 14 different QRS voltage criteria as well as our recently proposed criteria of S in V3 plus S in V4 in a population of 159 patients, of whom 14.5 % had echocardiographic evidence of LVH. Statistical analyses assessed the influence of age, sex, and hypertension on the sensitivity and specificity of each criterion. In addition, a machine learning model was used for enhanced diagnostic accuracy. RESULTS: The new SV3 + SV4 criterion had the highest F1 and AUC scores. Among traditional ECG criteria, the Peguero criterion showed the highest sensitivity (0.438), while Wilson and Mazeloni criteria demonstrated the highest specificity (0.9412). The new SV3 + SV4 criterion with sex-specific cut offs achieves a sensitivity of 0.500 and specificity of 0.809 in females, while in males, sensitivity reached 0.556 with specificity at 0.910. Multiple regression analysis indicated that age, sex, and hypertension significantly improved the diagnostic performance of specific criteria, including Sokolow-Lyon, Romhilt voltage, Murphy, and Grant criteria. However, other criteria were not impacted by considering age, sex, or hypertension. ML analysis improved diagnostic accuracy with clinical variables, with the highest performance in males with the addition of age (accuracy 0.959, sensitivity 0.556, and specificity 1.00). CONCLUSION: Considering age, sex, and hypertension can enhance the diagnostic performance of certain ECG criteria and especially in a ML model for LVH. Findings support a more individualized approach for LVH diagnosis in diverse patient populations.