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REVIEW 5 major objections 6 minor 35 references

In Silico Trials for Sex-Specific patient Inclusion Criteria in Cardiac Resynchronization Therapy: Advancing Precision in Heart Failure Treatment

T0 review · 5 major / 6 minor · reviewed 2026-08-07 · deepseek-v4-flash

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Pith's one-line read Height-indexed QRS duration tops CRT selection criteria in virtual trial

desk verdict Worth refereeing, but the height-indexed advantage is partly built into the model's assumptions; treat the clinical claims as hypothesis-generating. read the letter →

arxiv 2505.15708 v1 pith:4TSOQ323 submitted 2025-05-21 physics.med-ph q-bio.PE

Shuang Qian , Devran Ugurlu , Elliot Fairweather , Richard E Jones , Hassan Zaidi , Sanjay Prasad , Brian P Halliday , Daniel J Hammersley
show 7 more authors
Gernot Plank Edward Vigmond Christopher A Rinaldi Alistair Young Pablo Lamata Martin Bishop Steven Niederer
This is my paper · ORCID
classification physics.med-phq-bio.PE
keywords cardiacresynchronizationtherapyQRSdurationsexdifferencescomputersimulationvirtualcohortheartfailureleftbundlebranchblockpatientselection
verification ladder T0 review T1 audit T2 compute T3 formal

The pith

A machine-rendered reading of the paper's core claim, the machinery that carries it, and where it could break.

The reading

This paper uses computational 'virtual cohorts' to test whether current QRS-duration criteria for cardiac resynchronization therapy (CRT) unfairly exclude women. By simulating left bundle branch block and slow conduction in thousands of patient-specific heart models, the authors show that the standard 150 ms threshold selects fewer women with LBBB and more men without LBBB. They then compare alternative criteria that index QRS duration by heart volume, mass, or height. The central claim is that height-indexed QRS duration removes the sex imbalance while keeping the number of non-LBBB patients selected low, making it a more equitable and potentially more accurate basis for CRT guidelines.

What carries the argument

The machinery is a population-based in silico trial: patient-specific biventricular anatomical models (from CMR images) are activated with a fascicular model of His-Purkinje activation, and the reaction-eikonal model in CARP computes activation times and 12-lead ECGs from which QRSd is derived. Four scenarios (normal/LBBB activation × normal/slow conduction) are simulated per heart, and the resulting QRSd distributions are used to evaluate the sensitivity and specificity of conventional and indexed thresholds via ROC analysis. This allows controlled, mechanistic assessment of how sex, heart size, and pathological substrate affect QRSd-based patient selection, free from the selection bias of retrospective clinical cohorts.

What would settle it

A prospective observational study in a large mixed-sex heart failure cohort that measures QRSd, height, LVEDV, and CRT outcomes would falsify the claim if height-indexed QRSd did not outperform conventional QRSd in predicting LBBB status (by ECG morphology) or in predicting CRT response, or if it selected more non-responders. Specifically, if the height-indexed threshold's AUC were not at least as high as unindexed QRSd, the central superiority claim would fail.

Watch

Extended reading notes

Core claim

On the paper's own terms, the discovery is that height-indexed QRS duration (QRSd) is the best performing QRSd criterion for identifying LBBB patients who should receive CRT, across both healthy and ischemic heart disease anatomies and with or without slow conduction. Simulated QRSd values were generated for 2627 UK Biobank healthy participants and 359 ischemic heart disease patients under four pathological scenarios. Conventional thresholds (120, 130, 150 ms) under-selected LBBB females and over-selected non-LBBB males; indexing by LVEDV or LV mass reduced sex disparities but inflated false-positive selection; indexing by height (cutoffs 0.8 and 0.9 ms/cm) resolved the sex differences and maintained low non-LBBB selection rates. ROC analysis corroborated this: height-indexed QRSd outperformed volume- and mass-indexed criteria in all scenarios and matched or slightly exceeded conventional QRSd, with sex-specific optimal thresholds differing by only 0.01 ms/cm versus 7–13 ms for unindexed QRSd.

Load-bearing premise

The simulated QRSd values, generated with fixed conduction velocities and a fascicular activation model, are accurate and sex-fair enough to support threshold-level clinical recommendations, even though the simulations are not calibrated to each patient's measured QRSd.

Editorial extensions

If this is right

  • If height-indexed QRSd thresholds (e.g., 0.8–0.9 ms/cm) were adopted, more women with LBBB would receive CRT at QRS durations below 150 ms, potentially improving their outcomes.
  • Because height is already measured routinely, height-indexed criteria could be implemented in clinical practice at negligible cost.
  • The finding suggests that current CRT guidelines' sex differences in response may partly reflect biased selection rather than biology alone.
  • The virtual cohort approach could be extended to test other patient-selection criteria (e.g., imaging-based dyssynchrony) before running expensive trials.
  • The simulated result that most real CRT candidates are consistent with LBBB plus slow conduction could justify targeting both substrates in future device therapy.

Reading between the lines

Editorial extensions of the paper, not claims the author makes directly.

  • A testable extension: the same height-indexed logic might apply to other ECG intervals, such as QRS area or QT corrections, reducing sex bias in other device indications.
  • The simulation's reliance on fixed conduction velocities rather than patient-calibrated values is a key uncertainty; if true conduction velocity differs by sex beyond heart size, the height thresholds could be miscalibrated, and prospective clinical measurement of QRSd/height would settle this.
  • The comparison did not include a formal cost-benefit analysis or account for non-ischemic etiologies; height-indexed cutoffs may need adjustment in non-ischemic cardiomyopathy or in populations with different body-size distributions.
  • If height-indexed criteria were validated clinically, it would shift CRT guidelines from a single QRSd cutoff to a sex-independent one, potentially harmonizing US and European LBBB definitions.
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Editorial analysis

A structured set of objections, weighed in public.

Desk editor's note, referee report, and a circularity audit.

Referee Report

5 major / 6 minor

Summary. This manuscript proposes an in silico trial framework for evaluating sex-specific QRS duration (QRSd) criteria in cardiac resynchronization therapy (CRT) patient selection. Using 2627 UK Biobank healthy hearts and 359 ischemic heart disease (IHD) patient anatomies, the authors simulate four scenarios (normal or left bundle branch block (LBBB) activation crossed with normal or slowed conduction) with a fixed, sex-independent conduction velocity model, compute QRSd from simulated 12-lead ECGs, and compare conventional thresholds (120/130/150 ms) with QRSd indexed by LVEDV, LV mass, and height for classifying simulated LBBB versus non-LBBB patients, with sex-specific analyses and ROC comparisons. The central claim is that height-indexed QRSd resolves sex disparities in LBBB patient selection while maintaining low non-LBBB selection rates, and achieves the best classification performance among the indexed criteria under the simulated scenarios. The manuscript also reports a validation subset of 17 real CRT-indicated IHD patients to assess how well simulated QRSd reproduces clinical QRSd ≥150 ms.

Significance. The strengths of the paper are its scale and design: 2986 patient-specific ventricular anatomies, four controlled pathological scenarios, evaluation of criteria over the full QRSd distribution rather than only among patients already meeting guideline inclusion criteria, and formal ROC comparisons (DeLong test) with sex-stratified analyses. The finding that LVEDV/LV-mass indexing raises non-LBBB selection rates while height indexing does not is an emergent, internally consistent result, and the proposed framework is transferable to other selection-rule questions. The authors also ship the anatomical model generation pipeline as open source, and the height-indexed thresholds are concrete, falsifiable predictions that could be tested in prospective clinical cohorts. The main caveat is external validity: the simulations assign identical conduction velocities to both sexes, so the resolution of sex differences by height indexing is largely a consequence of the model's construction, and the simulated QRSd are systematically shorter than measured values in the same cohorts.

major comments (5)
  1. [Results, 'Basic patient characteristics'] The Results paragraph on measured QRSd states that in the healthy cohort QRSd were 'similar for both sexes (male: 93.2±23.8 ms vs 95.3±30.8 ms, P=0.7)', which directly contradicts Table 1, where healthy males and females have QRSd of 92.5±12.5 ms and 84±11.3 ms with P=8×10^-90, and also contradicts the Discussion's statement that 'significant sex differences in the baseline QRSds' were observed 'in both cohorts'. Since the paper's premise and its simulation target are sex differences in QRSd, this misreported result must be corrected and reconciled with Table 1.
  2. [Results, 'Which simulated pathological scenarios will meet the current criteria of CRT' versus Discussion] Figure 2 and the accompanying Results text report that under normal conduction scenarios 'none of their simulated QRSds surpassed 150 ms under normal conduction scenarios, regardless of LBBB or normal activation' (LBBB mean 113.2±13.3 ms), but the Discussion states that '6 of 17 cases simulated under LBBB and normal conduction exceeded the 150ms threshold'. A mean of 113.2±13.3 ms makes 6 of 17 values above 150 ms statistically implausible, so one of these passages is erroneous; the discrepancy is load-bearing because it is used to infer that real CRT candidates combine LBBB with slow conduction.
  3. [Methods, 'Electrophysiological (EP) simulations' and Results validation subset] The simulated QRSd are systematically shorter than the measured QRSd in the same cohorts: the healthy normal-activation simulation mean is 78.0 ms versus measured values of 84–92.5 ms (Table 1), and in the validation subset of 17 real CRT-indicated patients, the LBBB-plus-slow-conduction scenario brings only 88% (15/17) of patients above 150 ms although all 17 were included on the basis of measured QRSd ≥150 ms. The fixed conduction velocities (0.65 and 0.40 m/s), the subendocardial layer parameters, and the 0.15 spatial-velocity detection threshold are taken from literature medians and are never calibrated to the measured QRSd of these cohorts, and no sensitivity analysis is provided. Since the recommended height-indexed thresholds (e.g., 0.86 ms/cm) are absolute, a systematic bias in simulated QRSd—particularly one that interacts with sex or heart size—would directly shift the recommended thresholds; the authors should quantify this offset and its sex dependence, or temper the threshold-level claims.
  4. [Methods, 'Electrophysiological (EP) simulations' and Discussion] Because the same conduction velocities and the same fascicular activation model are applied to both sexes, all simulated sex differences in QRSd arise from anatomical heart-size differences, and height is used as a heart-size proxy. The observation that height-indexed QRSd 'effectively resolved sex differences' is therefore substantially built into the model's construction, and the supporting premise that real sex differences are entirely explained by heart size rests on prior work (ref 5, a medRxiv preprint). The ROC superiority of height indexing over LVEDV/LV-mass indexing is an emergent result, but the 'resolved sex disparities' claim should be reframed as a model prediction, and the robustness to the alternative hypothesis should be tested, for example by simulating a scenario with sex-specific conduction velocity or by directly comparing predicted versus measured sex differences in QRSd within the same cohorts.
  5. [Results, 'LBBB and non-LBBB Patient stratification'] The primary outcome is classification of simulated LBBB versus non-LBBB status, and selection of non-LBBB patients is labelled as a 'false positive' rate throughout. In current guidelines, however, non-LBBB patients with QRSd ≥150 ms are also CRT candidates (e.g., Class IIa in ESC 2021), so selecting non-LBBB patients with slow conduction is not necessarily a clinical error. The comparative claim that height-indexed criteria are 'the most reliable predictor for CRT patient selection' depends on this framing; the authors should either justify it with reference to expected benefit by pathology or soften the conclusion to LBBB-stratification performance.
minor comments (6)
  1. [Table 1] The IHD male QRSd entry reads '106.9.2±22.5' and should be '106.9±22.5'.
  2. [Results, 'LBBB and non-LBBB Patient stratification'] The sentence describing indexed-criteria selection rates begins '(range: [21.7–99.9%])' with an unmatched bracket, and the units '0.9 ms/m' and '0.86 ms/m' should be 'ms/cm' for consistency with the 0.8 and 0.9 ms/cm cutoffs defined earlier in the same section.
  3. [Results, 'Classification performance'] The sentence on sex-specific optimal thresholds states that male QRSd thresholds differ from female thresholds 'ranging from 7ms for healthy anatomies+normal conduction to 13 ms for healthy anatomies+normal conduction', naming the same scenario twice; one endpoint should refer to a different scenario.
  4. [Table 1 and heatmap analyses] The IHD cohort contains only 45 females (12.5%), so the sex-stratified selection-rate comparisons and P-values in the heatmaps carry wide confidence intervals; reporting these intervals (or at least noting the small denominator) would strengthen the interpretation.
  5. [References] Reference 5, which underpins the load-bearing assumption that sex differences in QRSd are entirely explained by heart size, is cited as a medRxiv preprint; a peer-reviewed version should be cited if available.
  6. [Discussion] The statement that the modelling approach is 'free from biases inherent in clinical trial recruitment' overstates the case, because the UK Biobank cohort and the single-center IHD cohort carry their own sampling and referral biases; a more careful wording would acknowledge these residual selection effects.

Circularity Check

2 steps flagged · score 6.0 of 10

Height-indexed QRSd advantage reduces by construction: sex-independent conduction velocities make heart size the only simulated source of sex differences, and height is used as a heart-size proxy.

  1. self definitional [Methods, 'Electrophysiological (EP) simulations'; Discussion, 'Height-indexed QRSd criteria emerged...']
    "Myocardium was simulated as a transversely isotropic medium with a conduction velocity of 0.65 m/s along fiber directions and an anisotropy ratio of 0.42 for the transverse fiber direction. ... Slowed cardiac conduction ... was simulated by reducing the model conduction velocity to 0.4 m/s ... Height-indexed QRSd criteria emerged as the most effective approach, resolving sex disparities in LBBB patient selection across most pathological scenarios ... These criteria leverage height, as a stable biomarker closely associated with baseline heart size."

    Because the same conduction velocities and identical fascicular activation are applied to all patients regardless of sex, the only sex-dependent variable in the simulated QRSd is anatomical heart size. Height is then used as a proxy for baseline heart size, so dividing QRSd by height removes exactly the sex-dependent input that the model itself created. The reported resolution of sex disparities is therefore a direct consequence of the simulation construction rather than an independently tested empirical relation.

  2. self citation load bearing [Introduction, first paragraph]
    "This was supported by our prior large-scale modelling study5 which showed how the shorter QRS duration in women can be entirely explained by smaller heart sizes, without intrinsic differences in myocardial conduction velocity."

    The premise that sex differences in QRSd are entirely explained by heart size is load-bearing for the height-indexed conclusion, but it is justified solely by citation to the authors' own prior modelling study (ref 5), which uses the same fixed-conduction-velocity assumption. The citation chain therefore does not add independent empirical support; the current model repeats the assumption and then 'finds' the expected height-indexed result.

full rationale

The paper's central claim that height-indexed QRSd resolves sex disparities is not an emergent empirical finding; it is encoded in the simulation. All patients are simulated with identical conduction velocities and identical fascicular activation, so sex differences in simulated QRSd can arise only from differences in heart size. Height is explicitly used as a proxy for baseline heart size, making height-indexed QRSd a normalization of the model's only sex-varying input. The paper's own prior study (ref 5) is cited to assert that heart size 'entirely explains' sex differences, and the same assumption is embedded in the current model. The ROC comparison between height, LVEDV, and LV-mass indexing is not forced and provides some independent content, as does the ordering against conventional QRSd; therefore the circularity is partial rather than total. The simulated QRSd values are also uncalibrated against measured QRSd (normal simulated ~78 ms vs 84-92 ms measured; only 88% of 17 real CRT patients cross 150 ms under LBBB+slow conduction), which would affect absolute thresholds but is a correctness/validity concern rather than circularity per se.

Assumptions & free parameters 7 free parameters · 6 assumptions · 0 invented entities

The central claim rests on two modeling choices: fixed conduction velocities and a simplified LBBB activation pattern, plus a height-as-heart-size-proxy assumption. None are fitted to the target result, but they control the simulated QRSd distributions. There are no invented physical entities.

free parameters (7)
  • Normal myocardial conduction velocity = 0.65 m/s
    Fixed from literature (ref 31) and applied to all patients; a different value would shift all simulated QRSd values and therefore all threshold-based conclusions.
  • Slowed conduction velocity = 0.40 m/s
    Chosen to represent pathological conduction slowing based on refs 34,35; this manual setting is the main driver of the separation between normal and slow conduction scenarios in the classification analysis.
  • QRSd onset/offset detection fraction = 0.15
    QRS duration was defined as time points where VCG spatial velocity exceeds 0.15 of its maximum; this hand-chosen threshold affects every computed QRSd.
  • Anisotropy ratio (transverse/fiber CV) = 0.42
    Taken from ref 31; affects simulated activation spread and sex/geometric QRSd differences.
  • Subendocardial layer CV ratio = 5
    Ratio of fast subendocardial conduction layer to myocardial CV, from refs 21,26,29,30; affects activation timing and QRSd.
  • Subendocardial layer transmural coordinate = 0.155
    From refs 21,26; determines thickness of fast layer, influencing simulated QRSd.
  • Fascicular site coordinates and firing times = Table 2 values
    All five early activation sites and their 15 ms firing times are fixed from anatomical literature; these define the normal and LBBB activation patterns and directly set the simulated QRSd.
assumptions (6)
  • standard math Reaction-eikonal model without diffusion accurately simulates ventricular activation for QRSd computation.
    Invoked in Methods 'Electrophysiological simulations' and justified by refs 19,20; it is a standard modeling assumption but unverified here for this population.
  • domain assumption LBBB can be represented by activating only the two right-ventricular fascicles and disabling the three left-ventricular fascicles.
    Methods and Figure 6; real LBBB includes varying septal activation and is diagnosed by ECG morphology, so this simplified activation pattern is load-bearing for the LBBB/non-LBBB classification.
  • domain assumption A single reference torso model with fixed electrode positions is sufficient to reconstruct 12-lead ECGs and QRSd for all patients.
    Methods state hearts were registered to a reference torso (ref 32); torso geometry and electrode location affect QRSd and could differ across patients.
  • domain assumption Fixed conduction velocities apply uniformly to all patients regardless of scar or fibrosis distribution.
    Slow conduction is simulated as a global CV reduction to 0.4 m/s, while real tissue has heterogeneous slowing; this affects the absolute QRSd values and classification rates.
  • domain assumption Height indexing is a valid normalization for heart size differences across sexes and disease states.
    Central claim relies on height as a proxy for heart size; if the height-heart size relationship differs between healthy, IHD, and remodelled hearts, the conclusion would weaken.
  • standard math Each simulated patient is an independent sample for statistical testing.
    Implicit in the Mann-Whitney U and ROC analyses; virtual patients share parameter values and may not be fully independent, but the impact is minor.

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Cite this review

Pith. "Pith review of In Silico Trials for Sex-Specific patient Inclusion Criteria in Cardiac Resynchronization Therapy: Advancing Precision in Heart Failure Treatment." pith.science (2026). https://pith.science/paper/4TSOQ323

@misc{pith2026250515708,
  author       = {Pith},
  title        = {Pith review of: In Silico Trials for Sex-Specific patient Inclusion Criteria in Cardiac Resynchronization Therapy: Advancing Precision in Heart Failure Treatment},
  year         = {2026},
  howpublished = {\url{https://pith.science/paper/4TSOQ323}},
  note         = {Machine review of arXiv:2505.15708}
}
read the original abstract

Cardiac resynchronization therapy (CRT) guidelines are based on clinical trials with limited female representation and inconsistent left bundle branch block (LBBB) definitions. Conventional QRS duration (QRSd) criteria show variable diagnostic accuracy between sexes, partly due to differences in heart size and remodeling. We evaluated the influence of sex, heart size, LBBB, and conduction delay on QRSd and assessed the diagnostic performance of conventional and indexed QRSd criteria using a population-based modelling approach. Simulated QRSd were derived from electrophysiological simulations conducted in 2627 UK Biobank healthy participants and 359 patients with ischemic heart disease, by modelling LBBB and normal activation combined with/without conduction delay. QRSd criteria under-selected LBBB females and over-selected non-LBBB patients. Indexing by LVEDV and LV mass reduced sex disparities but increased the over-selection in non-LBBB patients. Height-indexed QRSd effectively resolved sex differences and maintained low non-LBBB selection rates, demonstrating superior performance and potential for more equitable CRT selection.

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Reference graph

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Pith tools

Reviewed August 7, 2026 · model on record in the stance chip above.