The Influence of Age and Sex on the Electrocardiogram

  • Peter W. Macfarlane
Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 1065)


The electrocardiogram (ECG) remains the most commonly used test in medical practice and as such requires to be interpreted with due care and attention to detail. The ECG changes rapidly from birth through childhood with age differences clearly related to increasing QRS voltages and a widening QRS complex. The only sex difference at this age is a slightly longer QRS duration in boys than girls.

In adulthood, sex differences in QRS voltage are maximum in the under 40 age group and tend to minimise with advancing age. QRS duration is longer in males than in females, but little difference is made of this in diagnostic criteria. In a similar vein, ST amplitudes are higher in young males compared to young females with the difference diminishing as age increases. Corrected QT interval is longer in females than males.

In summary, age and gender differences in the ECG are important and have been incorporated into a variety of criteria for ECG interpretation. Physicians should be aware of the main sex differences in the ECG.


ECG Sex Age Reference values Normal ranges Databases Ethnicity Automated ECG analysis Diagnostic criteria QT interval JT interval 


  1. 1.
    Simonson E, Harris R. Differentiation between normal and abnormal in electrocardiography. St Louis: Mosby; 1961.Google Scholar
  2. 2.
    Stallman EW, Pipberger HV. Automatic recognition of electrocardiographic waves by digital computer. Circ Res. 1961;9:1138–43.CrossRefGoogle Scholar
  3. 3.
    Caceres CA, Steinberg CA, Abrahams S. Computer extraction of electrocardiographic parameters. Circulation. 1962;25:356–62.CrossRefPubMedGoogle Scholar
  4. 4.
    Bonner RE, et al. A new computer program for analysis of scalar electrocardiograms. Comput Biomed Res. 1972;5:629–53.CrossRefPubMedGoogle Scholar
  5. 5.
    Macfarlane PW, Devine B, Clark E. The University of Glasgow (Uni-G) ECG analysis program. Comput Cardiol. 2005;32:451–4.Google Scholar
  6. 6.
    Macfarlane PW, Systems L. In: Macfarlane PW, et al., editors. Comprehensive electrocardiology. London: Springer-Verlag; 2011. p. 375–425.Google Scholar
  7. 7.
    Fu Q. Hemodynamic and electrocardiographic aspects of uncomplicated singleton pregnancy. In: Kerkhof PLM, Miller VM, editors. Sex-specific analysis of cardiovascular function. Cham: Springer; 2018. pp. 413–31.Google Scholar
  8. 8.
    Macfarlane PW, Veitch Lawrie TD. The normal electrocardiogram and vectorcardiogram. In: Macfarlane PW, et al., editors. Comprehensive electrocardiology. London: Springer; 2011. p. 483–546.Google Scholar
  9. 9.
    Macfarlane PW. Adult normal limits. Appendix 1. In: Macfarlane PW, et al., editors. Comprehensive electrocardiology. London: Springer; 2011. p. 2057–83.Google Scholar
  10. 10.
    Macfarlane PW, et al. Normal limits of the high fidelity pediatric ECG: preliminary observations. J Electrocardiol. 1990;22(Suppl):162–8.CrossRefGoogle Scholar
  11. 11.
    Macfarlane PW, McLaughlin SC, Rodger JC. Influence of lead selection and population on automated measurement of QT. Circulation. 1998;98:2160–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Macfarlane PW. Paediatric normal limits. Appendix 2. In: Macfarlane P, et al., editors. Comprehensive electrocardiology. London: Springer; 2011. p. 2128–95.Google Scholar
  13. 13.
    Macfarlane PW, et al. A new 12 lead pediatric ECG interpretation program. J Electrocardiol. 1990;23(Suppl):76–81.CrossRefPubMedGoogle Scholar
  14. 14.
    Chen CY, Chiang BN, Macfarlane PW. Normal limits of the electrocardiogram in a Chinese population. J Electrocardiol. 1989;22:1–15.CrossRefPubMedGoogle Scholar
  15. 15.
    Katibi I. Establishment of normal limits of the electrocardiogram in healthy Nigerians using automated methods. Glasgow: Institute of Cardiovascular and Medical Sciences, University of Glasgow; 2011.Google Scholar
  16. 16.
    Katibi I, et al. Normal limits of the electrocardiogram in Nigerians. J Electrocardiol. 2013;46:289–95.CrossRefPubMedGoogle Scholar
  17. 17.
    Macfarlane PW, et al. Normal limits of the electrocardiogram in Indians. J Electrocardiol. 2015;48:652–68.CrossRefPubMedGoogle Scholar
  18. 18.
    Macfarlane PW, et al. Racial differences in the ECG – selected aspects. J Electrocardiol. 2014;47(6):809–8014.CrossRefPubMedGoogle Scholar
  19. 19.
    Morris JJ Jr, et al. P wave analysis in valvular heart disease. Circulation. 1964;29:242–52.CrossRefPubMedGoogle Scholar
  20. 20.
    Park MK, Guntheroth WG. How to read pediatric ECGs. St Louis: Mosby; 1992.Google Scholar
  21. 21.
    Fuchs A, et al. Normal values of left ventricular mass and cardiac chamber volumes assessed by 320-detector computed tomography angiography in the Copenhagen General Population Study. Eur Heart J Cardiovasc Imag. 2016;17:1009–17.CrossRefGoogle Scholar
  22. 22.
    Sokolow M, Lyon TP. The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. Am Heart J. 1949;37:161–86.CrossRefPubMedGoogle Scholar
  23. 23.
    Macfarlane PW, et al. Methodology of ECG interpretation in the Glasgow program. Methods Inf Med. 1990;29:354–61.CrossRefPubMedGoogle Scholar
  24. 24.
    Maron B, et al. Eligibility and disqualification recommendations for athletes with cardiovascular abnormalities: task force 2: Preparticipation screening for cardiovascular disease in competitive athletes. Circulation. 2015;132:e267–72.CrossRefPubMedGoogle Scholar
  25. 25.
    Corrado D, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol: consensus statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26:516–24.CrossRefPubMedGoogle Scholar
  26. 26.
    Corrado D, et al. Italian preparticipation screening for prevention of sudden cardiac death: it works! Br Med J. 2016;353:i1156.Google Scholar
  27. 27.
    Drezner JA, et al. International criteria for electrocardiographic interpretation in athletes: consensus statement. Br J Sports Med. 2017;51:704–31.CrossRefPubMedGoogle Scholar
  28. 28.
    Drezner JA, Ackerman MI, Anderson J. Electrocardiographic interpretation in athletes: the Seattle criteria. Br J Sports Med. 2013;47:122–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Casale PN, et al. Electrocardiographic detection of left ventricular hypertrophy: development and prospective validation of improved criteria. J Am Coll Cardiol. 1985;6:572–80.CrossRefPubMedGoogle Scholar
  30. 30.
    Casale PN, et al. Improved sex-specific criteria of left ventricular hypertrophy for clinical and computer interpretation of electrocardiograms: validation with autopsy findings. Circulation. 1987;75:565–72.CrossRefPubMedGoogle Scholar
  31. 31.
    Dahlof B, et al. Characteristics of 9194 patients with left ventricular hypertrophy: the LIFE Study. Hypertension. 1998;32:989–97.CrossRefPubMedGoogle Scholar
  32. 32.
    Macfarlane PW, Clark E, Cleland JGF. New criteria for LVH should be evaluated against age. J Am Coll Cardiol. 2017;70:2206–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Romhilt DW, Estes EH Jr. A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J. 1968;75:752–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Morrison I, Clark E, Macfarlane P. Evaluation of the electrocardiographic criteria for left ventricular hypertrophy. Anatolian J Cardiol. 2007;7(Suppl 1):159–63.Google Scholar
  35. 35.
    Strauss DG, et al. Defining left bundle branch block in the era of cardiac resynchronization therapy. Am J Cardiol. 2011;107:927–34.CrossRefPubMedGoogle Scholar
  36. 36.
    Macfarlane PW. Age, sex and the ST amplitude in health and disease. J Electrocardiol. 2001;34:235–41.CrossRefPubMedGoogle Scholar
  37. 37.
    Thygesen K, et al. Third Universal Definition of myocardial infarction. ESC/ACCF/AHA/WHF Expert Consensus Document. Circulation. 2009;53(11):1003–11.Google Scholar
  38. 38.
    Wagner GS, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram. Part VI: acute ischemia/infarction. A scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; The American College of Cardiology Foundation and the Heart Rhythm Society. J Am Coll Cardiol. 2009;53(11):1003–11.CrossRefPubMedGoogle Scholar
  39. 39.
    Macfarlane PW, et al. Evaluation of age and sex dependent criteria for ST elevation myocardial infarction. Comput Cardiol. 2007;34:293–6.Google Scholar
  40. 40.
    Clark EN, et al. Automated electrocardiogram interpretation programs versus cardiologists’ triage decision making based on Teletransmitted data in patients with suspected acute coronary syndrome. Am J Cardiol. 2010;106:1696–702.CrossRefPubMedGoogle Scholar
  41. 41.
    Papadakis M, et al. The prevalence, distribution and clinical outcomes of electrocardiographic repolarization patterns in male athletes of African/Afro-Caribbean origin. Eur Heart J. 2011;32:2304–13.CrossRefPubMedGoogle Scholar
  42. 42.
    Kligfield P, et al. Comparison of automated measurements of electrocardiographic intervals and durations by computer based algorithms of digital electrocardiographs. Am Heart J. 2014;167(2):150–159.e1.CrossRefPubMedGoogle Scholar
  43. 43.
    Bazett HC. An analysis of the time relations of electrocardiograms. Heart. 1920;20:353–70.Google Scholar
  44. 44.
    Vandenberg B, et al. Which QT correction formulae to use for QT monitoring? J Am Heart Assoc. 2016;5:e003264.CrossRefGoogle Scholar
  45. 45.
    Hodges M, Salerno D, Erlien D. Bazett’s QT correction reviewed. Evidence that a linear QT correction for heart is better. J Am Coll Cardiol. 1993;1:694. (Abstract)Google Scholar
  46. 46.
    Fridericia LS. Die Systolendauer im Elektrokardiogram bei normalen Menschen und bei Herzkranken. Acta Med Scand. 1920;53:469–86.CrossRefGoogle Scholar
  47. 47.
    Luo S, et al. A comparison of commonly used QT correction formulae: the effect of heart rate of the QTc of normal ECGs. J Electrocardiol. 2004;37(Suppl):81–90.CrossRefPubMedGoogle Scholar
  48. 48.
    Rautaharju PM, Surawicz B, Gettes LS. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram. Part IV: the ST segement and U waves, and the QT interval. A scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. J Am Coll Cardiol. 2009;53(11):982–91.CrossRefPubMedGoogle Scholar
  49. 49.
    Johannesen L, et al. Differentiating drug-induced multichannel block on the electrocardiogram: randomized study of dofetilide, quinidine, ranolazine and verapamil. Clin Pharmacol Ther. 2014;96:549–58.CrossRefPubMedGoogle Scholar
  50. 50.
    Rautaharju PM, et al. Assessment of prolonged QT and JT intervals in ventricular conduction defects. Am J Cardiol. 2004;93:1017–21.CrossRefPubMedGoogle Scholar
  51. 51.
    Symposium, The J-Tpeak Initiative. J Electrocardiol. 2017;50:748–75.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Institute of Health and WellbeingUniversity of GlasgowGlasgowUK

Personalised recommendations