Despite this remarkable progress, there is a noticeable absence of datasets that combine electrocardiogram (ECG) data with question answering.

Cardiovascular disease (CVD) continues to be the major cause of death globally, calling for predictive models that not only handle diverse and high-dimensional biomedical signals but also maintain interpretability and privacy. We create a single multimodal learning framework that integrates cross modal transformers with graph neural networks and causal representation learning to measure personalized CVD risk. The model combines genomic variation, cardiac MRI, ECG waveforms, wearable streams, and structured EHR data to predict risk while also implementing causal invariance constraints across different clinical subpopulations. To maintain transparency, we employ SHAP based feature attribution, counterfactual explanations and causal latent alignment for understandable risk factors. Besides, we position the design in a federated, privacy, preserving optimization protocol and establish rules for convergence, calibration and uncertainty quantification under distributional shift. Experimental studies based on large-scale biobank and multi institutional datasets reveal state discrimination and robustness, exhibiting fair performance across demographic strata and clinically distinct cohorts. This study paves the way for a principled approach to clinically trustworthy, interpretable and privacy respecting CVD prediction at the population level.

The electrocardiogram (ECG) is a key diagnostic tool in cardiovascular health. Single-lead ECG recording is integrated into both clinical-grade and consumer wearables. While self-supervised pretraining of foundation models on unlabeled ECGs improves diagnostic performance, existing approaches do not incorporate domain knowledge from clinical metadata. We introduce a novel contrastive learning approach that utilizes an established clinical risk score to adaptively weight negative pairs: clinically-guided contrastive learning. It aligns the similarities of ECG embeddings with clinically meaningful differences between subjects, with an explicit mechanism to handle missing metadata. On 12-lead ECGs from 161K patients in the MIMIC-IV dataset, we pretrain single-lead ECG foundation models at three scales, collectively called CLEF, using only routinely collected metadata without requiring per-sample ECG annotations. We evaluate CLEF on 18 clinical classification and regression tasks across 7 held-out datasets, and benchmark against 5 foundation model baselines and 3 self-supervised algorithms. When pretrained on 12-lead ECG data and tested on lead-I data, CLEF outperforms self-supervised foundation model baselines: the medium-sized CLEF achieves average AUROC improvements of at least 2.6% in classification and average reductions in MAEs of at least 3.2% in regression. Comparing with existing self-supervised learning algorithms, CLEF improves the average AUROC by at least 1.8%. Moreover, when pretrained only on lead-I data for classification tasks, CLEF performs comparably to the state-of-the-art ECGFounder, which was trained in a supervised manner. Overall, CLEF enables more accurate and scalable single-lead ECG analysis, advancing remote health monitoring. Code and pretrained CLEF models are available at: github.com/Nokia-Bell-Labs/ecg-foundation-model.

Cardiovascular disease (CVD) is a leading cause of mortality worldwide. Electrocardiograms (ECGs) are the most widely used non-invasive tool for cardiac assessment, yet large, well-annotated ECG corpora are scarce due to cost, privacy, and workflow constraints. Generating ECGs can be beneficial for the mechanistic understanding of cardiac electrical activity, enable the construction of large, heterogeneous, and unbiased datasets, and facilitate privacy-preserving data sharing. Generating realistic ECG signals from clinical context is important yet underexplored. Recent work has leveraged diffusion models for text-to-ECG generation, but two challenges remain: (i) existing methods often overlook the physiological simulator knowledge of cardiac activity; and (ii) they ignore broader, experience-based clinical knowledge grounded in real-world practice. To address these gaps, we propose SE-Diff, a novel physiological simulator and experience enhanced diffusion model for comprehensive ECG generation. SE-Diff integrates a lightweight ordinary differential equation (ODE)-based ECG simulator into the diffusion process via a beat decoder and simulator-consistent constraints, injecting mechanistic priors that promote physiologically plausible waveforms. In parallel, we design an LLM-powered experience retrieval-augmented strategy to inject clinical knowledge, providing more guidance for ECG generation. Extensive experiments on real-world ECG datasets demonstrate that SE-Diff improves both signal fidelity and text-ECG semantic alignment over baselines, proving its superiority for text-to-ECG generation. We further show that the simulator-based and experience-based knowledge also benefit downstream ECG classification.

The advent of multimodal large language models (MLLMs) has sparked interest in their application to electrocardiogram (ECG) analysis. However, existing ECG-focused MLLMs primarily focus on report generation tasks, often limited to single 12-lead, short-duration (10s) ECG inputs, thereby un-derutilizing the potential of MLLMs. To this end, we aim to develop a MLLM for ECG analysis that supports a broader range of tasks and more flexible ECG inputs. However, existing ECG-QA datasets are often monotonous. To address this gap, we first constructed the anyECG dataset, which encompasses a wide variety of tasks, including report generation, abnormal waveform localization, and open-ended question answering. In addition to standard hospital ECGs, we introduced long-duration reduced-lead ECGs for home environments and multiple ECG comparison scenarios commonly encountered in clinical practice. Furthermore, we propose the anyECG-chat model, which supports dynamic-length ECG inputs and multiple ECG inputs. We trained the model using a three-stage curriculum training recipe with the anyECG dataset. A comprehensive evaluation was conducted, demonstrating that anyECG-chat is capable of supporting various practical application scenarios, including not only common report generation tasks but also abnormal waveform localization for long-duration reduced-lead ECGs in home environments and comprehensive comparative analysis of multiple ECGs.

Wolff-Parkinson-White (WPW) syndrome is a cardiac electrophysiology (EP) disorder caused by the presence of an accessory pathway (AP) that bypasses the atrioventricular node, faster ventricular activation rate, and provides a substrate for atrio-ventricular reentrant tachycardia (AVRT). Accurate localization of the AP is critical for planning and guiding catheter ablation procedures. While traditional diagnostic tree (DT) methods and more recent machine learning (ML) approaches have been proposed to predict AP location from surface electrocardiogram (ECG), they are often constrained by limited anatomical localization resolution, poor interpretability, and the use of small clinical datasets. In this study, we present a Deep Learning (DL) model for the localization of single manifest APs across 24 cardiac regions, trained on a large, physiologically realistic database of synthetic ECGs generated using a personalized virtual heart model. We also integrate eXplainable Artificial Intelligence (XAI) methods, Guided Backpropagation, Grad-CAM, and Guided Grad-CAM, into the pipeline. This enables interpretation of DL decision-making and addresses one of the main barriers to clinical adoption: lack of transparency in ML predictions. Our model achieves localization accuracy above 95%, with a sensitivity of 94.32% and specificity of 99.78%. XAI outputs are physiologically validated against known depolarization patterns, and a novel index is introduced to identify the most informative ECG leads for AP localization. Results highlight lead V2 as the most critical, followed by aVF, V1, and aVL. This work demonstrates the potential of combining cardiac digital twins with explainable DL to enable accurate, transparent, and non-invasive AP localization.

The coupling signal refers to a latent physiological signal that characterizes the transformation from cardiac electrical excitation, captured by the electrocardiogram (ECG), to mechanical contraction, recorded by the phonocardiogram (PCG). By encoding the temporal and functional interplay between electrophysiological and hemodynamic events, it serves as an intrinsic link between modalities and offers a unified representation of cardiac function, with strong potential to enhance multi-modal cardiovascular disease (CVD) detection. However, existing coupling signal estimation methods remain highly vulnerable to noise, particularly in real-world clinical and physiological settings, which undermines their robustness and limits practical value. In this study, we propose Noise-Robust Multi-Modal Coupling Signal Estimation (NMCSE), which reformulates coupling signal estimation as a distribution matching problem solved via optimal transport. By jointly aligning amplitude and timing, NMCSE avoids noise amplification and enables stable signal estimation. When integrated into a Temporal-Spatial Feature Extraction (TSFE) network, the estimated coupling signal effectively enhances multi-modal fusion for more accurate CVD detection. To evaluate robustness under real-world conditions, we design two complementary experiments targeting distinct sources of noise. The first uses the PhysioNet 2016 dataset with simulated hospital noise to assess the resilience of NMCSE to clinical interference. The second leverages the EPHNOGRAM dataset with motion-induced physiological noise to evaluate intra-state estimation stability across activity levels. Experimental results show that NMCSE consistently outperforms existing methods under both clinical and physiological noise, highlighting it as a noise-robust estimation approach that enables reliable multi-modal cardiac detection in real-world conditions.

Clinical 12-lead ECG classification remains difficult because of diverse recording conditions, overlapping pathologies, and pronounced label imbalance hinder generalization, while unconstrained augmentations risk distorting diagnostically critical morphology. In this study, Sinusoidal Time--Amplitude Resampling (STAR) is introduced as a beat-wise augmentation that operates strictly between successive R-peaks to apply controlled time warping and amplitude scaling to each R--R segment, preserving the canonical P--QRS--T order and leaving the head and tail of the trace unchanged. STAR is designed for practical pipelines and offers: (i) morphology-faithful variability that broadens training diversity without corrupting peaks or intervals; (ii) source-resilient training, improving stability across devices, sites, and cohorts without dataset-specific tuning; (iii) model-agnostic integration with common 1D SE--ResNet-style ECG encoders backbone; and (iv) better learning on rare classes via beat-level augmentation, reducing overfitting by resampling informative beats instead of duplicating whole records. In contrast to global crops, large shifts, or additive noise, STAR avoids transformations that suppress or misalign clinical landmarks. A complete Python implementation and a transparent training workflow are released, aligned with a source-aware, stratified five-fold protocol over a multi-institutional 12-lead corpus, thereby facilitating inspection and reuse. Taken together, STAR provides a simple and controllable augmentation for clinical ECG classification where trustworthy morphology, operational simplicity, and cross-source durability are essential.