Background and Aims: The electrocardiogram (ECG) is routinely used for diagnosis and risk stratification following myocardial infarction (MI), though its interpretation is confounded by anatomical variability and sex differences. Women have a higher incidence of missed MI diagnosis and poorer outcomes following infarction. Sex differences in ECG biomarkers and torso-ventricular anatomy have not been well characterised, largely due to the absence of high-throughput torso reconstruction methods. Methods: This work presents quantification of sex differences in ECG versus anatomical biomarkers in healthy and post-MI subjects, enabled by a novel, end-to-end automated pipeline for torso-ventricular anatomical reconstruction from clinically standard cardiac magnetic resonance imaging. Personalised 3D torso-ventricular reconstructions were generated for 425 post-MI subjects and 1051 healthy controls from the UK Biobank. Regression models were created relating the extracted torso-ventricular and ECG parameters. Results: Half the sex difference in QRS durations is explained by smaller ventricles in women both in healthy ($3.4 \pm 1.3$ms of $6.0 \pm 1.5$ms) and post-MI ($4.5 \pm 1.4$ms of $8.3 \pm 2.5$ms) subjects. Lower baseline STj amplitude in women is also associated with smaller ventricles, and more superior and posterior cardiac position. Post-MI T wave amplitude and R axis deviations are more strongly associated with a more posterior and horizontal cardiac position in women rather than electrophysiology as in men. Conclusion: A novel computational pipeline enables the three-dimensional reconstruction of 1476 torso-cardiac geometries of healthy and post-myocardial infarction subjects, quantification of sex and BMI-related differences and association with ECG biomarkers. Any ECG-based tool should be reviewed considering anatomical sex differences to avoid sex-biased outcomes.

翻译：背景与目的：心电图（ECG）常规用于心肌梗死（MI）后的诊断和风险分层，但其解读常受解剖变异性和性别差异的干扰。女性存在更高的心梗漏诊率及更差的梗死后预后。由于缺乏高通量躯干重建方法，ECG生物标志物与躯干-心室解剖结构的性别差异尚未得到充分表征。方法：本研究通过一种新型端到端自动化流程，从临床标准心脏磁共振成像中重建躯干-心室解剖结构，首次量化了健康人群与心梗后患者ECG与解剖生物标志物的性别差异。基于英国生物银行数据，为425名心梗后患者和1051名健康对照者生成了个性化三维躯干-心室重建模型。通过回归模型分析提取的躯干-心室参数与ECG参数间的关联。结果：女性较短的QRS时程中约半数差异可由其较小的心室体积解释，该现象在健康人群（$6.0 \pm 1.5$ms中的$3.4 \pm 1.3$ms）和心梗后患者（$8.3 \pm 2.5$ms中的$4.5 \pm 1.4$ms）中均存在。女性较低的基线STj振幅亦与较小心室体积、更靠上及靠后的心脏位置相关。心梗后T波振幅与R轴偏移在女性中与更靠后、更水平的心脏位置关联更强，而男性则主要与电生理特性相关。结论：新型计算流程实现了1476例健康与心梗后个体躯干-心脏三维几何重建，量化了性别与BMI相关差异及其与ECG生物标志物的关联。所有基于ECG的诊断工具均应结合解剖学性别差异进行校准，以避免性别偏倚的临床结果。