From Wrist to Heart: Clinical Validation and Real-World Translation of Wearable & Portable AI-enhanced ECG

Abstract Wearable and portable electrocardiogram devices are shifting cardiovascular monitoring beyond clinician-directed testing, driven by consumer-led self-monitoring, remote care, and preventative cardiology. Artificial intelligence may enhance the value of these devices by supporting automated interpretation, but clinical translation remains uneven. This narrative review synthesises current evidence on artificial intelligence-enhanced electrocardiogram analysis in wearable and portable systems, with emphasis on the gap between technical performance and real-world implementation. Although many advances have been developed using conventional 12-lead electrocardiogram datasets, deployment in wearable and portable devices introduces additional challenges related to device-specific signal acquisition, preprocessing, domain shift, and user-led recording. Evidence is most mature for atrial fibrillation detection, while applications across conduction disease, other arrhythmias, structural phenotypes, and prognostic assessment remain earlier in development and are supported by fewer prospective, device-specific evaluations. Across the field, retrospective and dataset-based studies predominate, with limited evidence that improved detection translates into better patient outcomes or health-system efficiency. Future research should evaluate performance using the intended device, population, and clinical pathway, and determine whether AI-ECG changes management without increasing unnecessary investigation or workload. Establishing clinical value, rather than improving classification accuracy alone, will determine the role of wearable and portable AI-ECG in routine cardiovascular care.