Interest in generative Electrocardiogram-Language Models (ELMs) is growing, as they can produce textual responses conditioned on ECG signals and textual queries. Unlike traditional classifiers that output label probabilities, ELMs are more versatile, supporting domain-specific tasks (e.g., waveform analysis, diagnosis, prognosis) as well as general tasks (e.g., open-ended questions, dialogue). Retrieval-Augmented Generation (RAG), widely used in Large Language Models (LLMs) to ground LLM outputs in retrieved knowledge, helps reduce hallucinations and improve natural language generation (NLG). However, despite its promise, no open-source implementation or systematic study of RAG pipeline design for ELMs currently exists. To address this gap, we present the first open-source RAG pipeline for ELMs, along with baselines and ablation studies for NLG. Experiments on three public datasets show that ELMs with RAG consistently improves performance over non-RAG baselines and highlights key ELM design considerations. Our code is available at: https://github.com/willxxy/ECG-Bench.

Large Language Models (LLMs) have shown remarkable adaptability across domains beyond text, specifically electrocardiograms (ECGs). More specifically, there is a growing body of work exploring the task of generating text from a multi-channeled ECG and corresponding textual prompt. Current approaches typically involve pretraining an ECG-specific encoder with a self-supervised learning (SSL) objective and using the features output by the pretrained encoder to finetune a LLM for natural language generation (NLG). However, these methods are limited by 1) inefficiency from two-stage training and 2) interpretability challenges with encoder-generated features. To address these limitations, we introduce ECG-Byte, an adapted byte pair encoding (BPE) tokenizer pipeline for autoregressive language modeling of ECGs. This approach compresses and encodes ECG signals into tokens, enabling end-to-end LLM training by combining ECG and text tokens directly, while being much more interpretable since the ECG tokens can be directly mapped back to the original signal. Using ECG-Byte, we achieve competitive performance in NLG tasks in only half the time and ~48% of the data required by two-stage approaches.