Multicenter validation of AI-enabled ECG for pediatric biological sex prediction.

O'Sullivan, Donnchadh; Mayourian, Joshua; Anjewierden, Scott; Liu, Kan; Attia, Zachi Itzhak; Lopez-Jimenez, Francisco; Friedman, Paul A; Doan, Tam et al. · NPJ Digit Med · 2026

cross_sectional · Level IV

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Abstract

Biological sex is closely linked to patterns embedded within the electrocardiogram (ECG) with essential health and disease implications. We report multicenter verification of an AI-enabled ECG model to predict biological sex across pediatric development. A previously published Mayo Clinic model confirmed puberty-linked AUROC gradient during external validation at Texas Children's Hospital (pre-puberty AUROC 0.64, peri-puberty AUROC 0.84, post-puberty AUROC 0.94). This phenomenon was replicated at Boston Children's Hospital. Saliency mapping revealed established sex-related electrophysiologic patterns.