Early detection of risk of heart failure with reduced ejection fraction remains challenging in resource-limited settings due to limited access to echocardiography. Artificial intelligence electrocardiogram (AI-ECG) algorithms have demonstrated promise for identifying left ventricular systolic dysfunction (LVSD), but their feasibility in resource-constrained settings remains unknown. To determine the frequency of patients in Kenya with a high probability of LVSD by AI-ECG and assess AI-ECG algorithm performance against the gold standard of echocardiography. This was a cross-sectional study with enrollment from June to December 2024. Participants underwent baseline assessment and 12-lead ECG, and a subset completed echocardiography within 7 days. The echocardiography subset included participants from 3 prespecified risk strata: those with prior cardiovascular disease, those at high cardiovascular risk (Framingham Risk Score [FRS] ≥10%), and those at low risk (FRS <10%). The study took place at 8 outpatient health care facilities across Kenya. A total of 1444 patients 18 years and older seeking routine care were enrolled and completed paired echocardiogram. Exclusion criteria included inability to provide informed consent. Risk of LVSD was identified using a validated convolutional neural network AI-ECG algorithm (AiTiALVSD). Key outcomes were the diagnostic performance (sensitivity, specificity, and positive and negative predictive values) of the AI-ECG algorithm for detecting LVSD (LVEF <40%) when confirmed on echocardiography. Among 1444 participants (mean [SD] age, 59.0 [16.7] years; 907 [62.8%] female; 1118 [77.4%] at high risk), LVSD was identified in 204 (14.1%). The AI-ECG algorithm had a sensitivity of 95.6% (95% CI, 91.8-97.7), specificity of 79.4% (95% CI, 77.0-81.5), positive predictive value of 43.2% (95% CI, 38.7-47.9), negative predictive value of 99.1% (95% CI, 98.3-99.5), and area under the receiver operating characteristic curve (AUC) of 0.96 (95% CI, 0.95-0.97). Performance remained consistent across cardiovascular risk strata (AUC, 0.96-0.98). In this study, the AI-ECG algorithm demonstrated the potential clinical utility for screening of LVSD risk with high sensitivity and negative predictive value and may be particularly scalable in a resource-limited setting.