Anatomical basis of sex differences in the electrocardiogram identified by three-dimensional torso-heart imaging reconstruction pipeline

Reviewer #1 (Public review):

Summary:

The electrocardiogram (ECG) is routinely used to diagnose and assess cardiovascular risk. However, its interpretation can be complicated by sex-based and anatomical variations in heart and torso structure. To quantify these relationships, Dr. Smith and colleagues developed computational tools to automatically reconstruct 3D heart and torso anatomies from UK Biobank data. Their regression analysis identified key sex differences in anatomical parameters and their associations with ECG features, particularly post-myocardial infarction (MI). This work provides valuable quantitative insights into how sex and anatomy influence ECG metrics, potentially improving future ECG interpretation protocols by accounting for these factors.

Strengths:

(1) The study introduces an automated pipeline to reconstruct heart and torso anatomies from a large cohort (1,476 subjects, including healthy and post-MI individuals).

(2) The 3-stage reconstruction achieved high accuracy (validated via Dice coefficient and error distances).

(3) Extracted anatomical features enabled novel analyses of disease-dependent relationships between sex, anatomy, and ECG metrics.

(4) Open-source code for the pipeline and analyses enhances reproducibility.

Weaknesses:

(1) The linear regression approach, while useful, may not fully address collinearity among parameters (e.g., cardiac size, torso volume, heart position). Although left ventricular mass or cavity volume was selected to mitigate collinearity, other parameters (e.g., heart center coordinates) could still introduce bias.

(2) The study attributes residual ECG differences to sex/MI status after controlling for anatomical variables. However, regression model errors could distort these estimates. A rigorous evaluation of potential deviations (e.g., variance inflation factors or alternative methods like ridge regression) would strengthen the conclusions.

(3) The manuscript's highly quantitative presentation may hinder readability. Simplifying technical descriptions and improving figure clarity (e.g., separating superimposed bar plots in Figures 2-4) would aid comprehension.

(4) Given established sex differences in QTc intervals, applying the same analytical framework to explore QTc's dependence on sex and anatomy could have provided additional clinically relevant insights.

Reviewer #2 (Public review):

Summary:

Missed diagnosis of myocardial ischemia (MI) is more common in women, and treatment is typically less aggressive. This diagnosis stems from the fact that women's ECGs commonly exhibit 12 lead ECG biomarkers that are less likely to fall within the traditional diagnostic criteria. Namely, women have shorter QRS durations and lower ST junction and T wave amplitudes, but longer QT intervals, than men. To study the impact, this study aims to quantify sex differences in heart-torso anatomy and ECG biomarkers, as well as their relative associations, in both pre- and post-MI populations. A novel computational pipeline was constructed to generate torso-ventricular geometries from cardiac magnetic resonance imaging. The pipeline was used to build models for 425 post-myocardial infarction subjects and 1051 healthy controls from UK Biobank clinical images to generate the population.

Strengths:

This study has a strength in that it utilizes a large patient population from the UK Biobank (425 post-MI and 1051 healthy controls) to analyze sex-based differences. The computational pipeline is state-of-the-art for constructing torso-ventricular geometries from cardiac MR and is clinically viable. It draws on novel machine learning techniques for segmentation, contour extraction, and shape modeling. This pipeline is publicly available and can help in the large-scale generation of anatomies for other studies. This allows computation of various anatomical factors (torso volume, cavity volume, etc), and subsequent regression analysis on how these factors are altered before and after MI from the 12-lead ECG.

Weaknesses:

Major weaknesses stem from the fact that, while electrophysiological factors appear to play a role across many leads, both post-MI and healthy, the electrophysiological factors are not stated or discussed. The computational modeling pipeline is validated for reconstructing torso contours; however, potential registration errors stemming from ventricular-torso construction are not addressed within the context of anatomical factors, such as the tilt and rotation of the heart. This should be discussed as the paper's claims are based on these results. Further analysis and explanation are needed to understand how these sex-specific results impact the ECG-based diagnosis of MI in men and women, as stated as the primary reason for the study at the beginning of the paper. This would provide a broader impact within the clinical community. Claims about demographics do not appear to be supported within the main manuscript but are provided in the supplements. Reformatting the paper's structure is required to efficiently and effectively present and support the findings and outcomes of this work.