Twelve-lead electrocardiograms (ECGs) are the clinical gold standard for cardiac diagnosis, providing comprehensive spatial coverage of the heart necessary to detect conditions such as myocardial infarction (MI). However, their lack of portability limits continuous and large-scale use. Three-lead ECG systems are widely used in wearable devices due to their simplicity and mobility, but they often fail to capture pathologies in unmeasured regions. To address this, we propose WearECG, a Variational Autoencoder (VAE) method that reconstructs twelve-lead ECGs from three leads: II, V1, and V5. Our model includes architectural improvements to better capture temporal and spatial dependencies in ECG signals. We evaluate generation quality using MSE, MAE, and Frechet Inception Distance (FID), and assess clinical validity via a Turing test with expert cardiologists. To further validate diagnostic utility, we fine-tune ECGFounder, a large-scale pretrained ECG model, on a multi-label classification task involving over 40 cardiac conditions, including six different myocardial infarction locations, using both real and generated signals. Experiments on the MIMIC dataset show that our method produces physiologically realistic and diagnostically informative signals, with robust performance in downstream tasks. This work demonstrates the potential of generative modeling for ECG reconstruction and its implications for scalable, low-cost cardiac screening.

LLMs have emerged as powerful tools for interpreting multimodal data. In medicine, they hold particular promise for synthesizing large volumes of clinical information into actionable insights and digital health applications. Yet, a major limitation remains their inability to handle time series. To overcome this gap, we present OpenTSLM, a family of Time Series Language Models (TSLMs) created by integrating time series as a native modality to pretrained LLMs, enabling reasoning over multiple time series of any length. We investigate two architectures for OpenTSLM. The first, OpenTSLM-SoftPrompt, models time series implicitly by concatenating learnable time series tokens with text tokens via soft prompting. Although parameter-efficient, we hypothesize that explicit time series modeling scales better and outperforms implicit approaches. We thus introduce OpenTSLM-Flamingo, which integrates time series with text via cross-attention. We benchmark both variants against baselines that treat time series as text tokens or plots, across a suite of text-time-series Chain-of-Thought (CoT) reasoning tasks. We introduce three datasets: HAR-CoT, Sleep-CoT, and ECG-QA-CoT. Across all, OpenTSLM models outperform baselines, reaching 69.9 F1 in sleep staging and 65.4 in HAR, compared to 9.05 and 52.2 for finetuned text-only models. Notably, even 1B-parameter OpenTSLM models surpass GPT-4o (15.47 and 2.95). OpenTSLM-Flamingo matches OpenTSLM-SoftPrompt in performance and outperforms on longer sequences, while maintaining stable memory requirements. By contrast, SoftPrompt grows exponentially in memory with sequence length, requiring around 110 GB compared to 40 GB VRAM when training on ECG-QA with LLaMA-3B. Expert reviews by clinicians find strong reasoning capabilities exhibited by OpenTSLMs on ECG-QA. To facilitate further research, we provide all code, datasets, and models open-source.

Complex numerical time series analysis often demands multi-step reasoning capabilities beyond current models' reach. Tasks like medical diagnosis and weather forecasting require sequential reasoning processes -- including counterfactual analysis, logical deduction, knowledge application, and multi-modal contextual integration -- that existing time series models cannot explicitly perform. While recent research has shown large language models (LLMs) can achieve sophisticated Chain-of-Thought (CoT) reasoning through reinforcement learning (RL), these advances have primarily focused on mathematical and coding domains, with LLMs still demonstrating poor performance on time series tasks. We introduce Chain Of thought for Understanding Numerical Time Series (COUNTS), the first framework that trains LLMs to perform CoT reasoning across diverse time series tasks using RL with verifiable rewards. Our approach employs a Residual Vector-Quantized VAE to create high-fidelity discrete tokens that seamlessly integrate into a pre-trained LLM's vocabulary. COUNTS undergoes a two-stage training process: first, supervised fine-tuning on time series analysis tasks to master our novel representations, followed by Group Relative Policy Optimization training on verifiable problems using prompting strategies that encourage explicit reasoning steps before producing final answers. Our experiments demonstrate that this RL-driven approach with intermediate CoT reasoning significantly enhances LLM performance across various time series analysis tasks, opening new possibilities for complex temporal data reasoning.

-- Cardiovascular diseases (CVDs) remain a leading cause of mortality worldwide, underscoring the importance of accurate and scalable diagnostic systems. Electrocardiogram (ECG) analysis is central to detecting cardiac abnormalities, yet challenges such as noise, class imbalance, and dataset heterogeneity limit current methods. To address these issues, we propose Foun-dationalECGNet, a foundational framework for automated ECG classification. The model integrates a dual-stage de-noising by Morlet and Daubechies wavelets transformation, Convolutional Block Attention Module (CBAM), Graph Attention Networks (GAT), and Time Series Transformers (TST) to jointly capture spatial and temporal dependencies in multi-channel ECG signals. FoundationalECGNet first distinguishes between Normal and Abnormal ECG signals, and then classifies the Abnormal signals into one of five cardiac conditions: Arrhythmias, Conduction Disorders, Myocardial Infarction, QT Abnormalities, or Hypertrophy. Across multiple datasets, the model achieves a 99% F1-score for Normal vs. Abnormal classification and shows state-of-the-art performance in multi-class disease detection, including a 99% F1-score for Conduction Disorders and Hypertrophy, as well as a 98.9% F1-score for Arrhythmias. Additionally, the model provides risk level estimations to facilitate clinical decision-making. In conclusion, FoundationalECGNet represents a scalable, interpretable, and generalizable solution for automated ECG analysis, with the potential to improve diagnostic precision and patient outcomes in healthcare settings. ARDIOV ASCULAR diseases (CVDs) are the leading cause of death worldwide, leading to approximately 17.9 million deaths each year [45].

Cardiovascular diseases (CVDs) remain the leading cause of mortality worldwide, highlighting the critical need for efficient and accurate diagnostic tools. Electrocardiograms (ECGs) are indispensable in diagnosing various heart conditions; however, their manual interpretation is time-consuming and error-prone. In this paper, we propose xLSTM-ECG, a novel approach that leverages an extended Long Short-Term Memory (xLSTM) network for multi-label classification of ECG signals, using the PTB-XL dataset. To the best of our knowledge, this work represents the first design and application of xLSTM modules specifically adapted for multi-label ECG classification. Our method employs a Short-Time Fourier Transform (STFT) to convert time-series ECG waveforms into the frequency domain, thereby enhancing feature extraction. The xLSTM architecture is specifically tailored to address the complexities of 12-lead ECG recordings by capturing both local and global signal features. Comprehensive experiments on the PTB-XL dataset reveal that our model achieves strong multi-label classification performance, while additional tests on the Georgia 12-Lead dataset underscore its robustness and efficiency. This approach significantly improves ECG classification accuracy, thereby advancing clinical diagnostics and patient care. The code will be publicly available upon acceptance.

Objective: Electronic health records (EHR) are widely available to complement administrative data-based disease surveillance and healthcare performance evaluation. Defining conditions from EHR is labour-intensive and requires extensive manual labelling of disease outcomes. This study developed an efficient strategy based on advanced large language models to identify multiple conditions from EHR clinical notes. Methods: We linked a cardiac registry cohort in 2015 with an EHR system in Alberta, Canada. We developed a pipeline that leveraged a generative large language model (LLM) to analyze, understand, and interpret EHR notes by prompts based on specific diagnosis, treatment management, and clinical guidelines. The pipeline was applied to detect acute myocardial infarction (AMI), diabetes, and hypertension. The performance was compared against clinician-validated diagnoses as the reference standard and widely adopted International Classification of Diseases (ICD) codes-based methods. Results: The study cohort accounted for 3,088 patients and 551,095 clinical notes. The prevalence was 55.4%, 27.7%, 65.9% and for AMI, diabetes, and hypertension, respectively. The performance of the LLM-based pipeline for detecting conditions varied: AMI had 88% sensitivity, 63% specificity, and 77% positive predictive value (PPV); diabetes had 91% sensitivity, 86% specificity, and 71% PPV; and hypertension had 94% sensitivity, 32% specificity, and 72% PPV. Compared with ICD codes, the LLM-based method demonstrated improved sensitivity and negative predictive value across all conditions. The monthly percentage trends from the detected cases by LLM and reference standard showed consistent patterns.

Predictive modelling is vital to guide preventive efforts. Whilst large-scale prospective cohort studies and a diverse toolkit of available machine learning (ML) algorithms have facilitated such survival task efforts, choosing the best-performing algorithm remains challenging. Benchmarking studies to date focus on relatively small-scale datasets and it is unclear how well such findings translate to large datasets that combine omics and clinical features. We sought to benchmark eight distinct survival task implementations, ranging from linear to deep learning (DL) models, within the large-scale prospective cohort study UK Biobank (UKB). We compared discrimination and computational requirements across heterogenous predictor matrices and endpoints. Finally, we assessed how well different architectures scale with sample sizes ranging from n = 5,000 to n = 250,000 individuals. Our results show that discriminative performance across a multitude of metrices is dependent on endpoint frequency and predictor matrix properties, with very robust performance of (penalised) COX Proportional Hazards (COX-PH) models. Of note, there are certain scenarios which favour more complex frameworks, specifically if working with larger numbers of observations and relatively simple predictor matrices. The observed computational requirements were vastly different, and we provide solutions in cases where current implementations were impracticable. In conclusion, this work delineates how optimal model choice is dependent on a variety of factors, including sample size, endpoint frequency and predictor matrix properties, thus constituting an informative resource for researchers working on similar datasets. Furthermore, we showcase how linear models still display a highly effective and scalable platform to perform risk modelling at scale and suggest that those are reported alongside non-linear ML models.

While recent multimodal large language models (MLLMs) have advanced automated ECG interpretation, they still face two key limitations: (1) insufficient multimodal synergy between time series signals and visual ECG representations, and (2) limited explainability in linking diagnoses to granular waveform evidence. We introduce GEM, the first MLLM unifying ECG time series, 12-lead ECG images and text for grounded and clinician-aligned ECG interpretation. GEM enables feature-grounded analysis, evidence-driven reasoning, and a clinician-like diagnostic process through three core innovations: a dual-encoder framework extracting complementary time series and image features, cross-modal alignment for effective multimodal understanding, and knowledge-guided instruction generation for generating high-granularity grounding data (ECG-Grounding) linking diagnoses to measurable parameters ($e.g.$, QRS/PR Intervals). Additionally, we propose the Grounded ECG Understanding task, a clinically motivated benchmark designed to comprehensively assess the MLLM's capability in grounded ECG understanding. Experimental results on both existing and our proposed benchmarks show GEM significantly improves predictive performance (CSN $7.4\% \uparrow$), explainability ($22.7\% \uparrow$), and grounding ($24.8\% \uparrow$), making it more suitable for real-world clinical applications. GitHub repository: https://github.com/lanxiang1017/GEM.git

Recent advances in multimodal ECG representation learning center on aligning ECG signals with paired free-text reports. However, suboptimal alignment persists due to the complexity of medical language and the reliance on a full 12-lead setup, which is often unavailable in under-resourced settings. To tackle these issues, we propose **K-MERL**, a knowledge-enhanced multimodal ECG representation learning framework. **K-MERL** leverages large language models to extract structured knowledge from free-text reports and employs a lead-aware ECG encoder with dynamic lead masking to accommodate arbitrary lead inputs. Evaluations on six external ECG datasets show that **K-MERL** achieves state-of-the-art performance in zero-shot classification and linear probing tasks, while delivering an average **16%** AUC improvement over existing methods in partial-lead zero-shot classification.

Acute Coronary Syndromes (ACS), including ST-segment elevation myocardial infarctions (STEMI) and non-ST-segment elevation myocardial infarctions (NSTEMI), remain a leading cause of mortality worldwide. Traditional cardiovascular risk scores rely primarily on clinical data, often overlooking environmental influences like air pollution that significantly impact heart health. Moreover, integrating complex time-series environmental data with clinical records is challenging. We introduce TabulaTime, a multimodal deep learning framework that enhances ACS risk prediction by combining clinical risk factors with air pollution data. TabulaTime features three key innovations: First, it integrates time-series air pollution data with clinical tabular data to improve prediction accuracy. Second, its PatchRWKV module automatically extracts complex temporal patterns, overcoming limitations of traditional feature engineering while maintaining linear computational complexity. Third, attention mechanisms enhance interpretability by revealing interactions between clinical and environmental factors. Experimental results show that TabulaTime improves prediction accuracy by over 20% compared to conventional models such as CatBoost, Random Forest, and LightGBM, with air pollution data alone contributing over a 10% improvement. Feature importance analysis identifies critical predictors including previous angina, systolic blood pressure, PM10, and NO2. Overall, TabulaTime bridges clinical and environmental insights, supporting personalized prevention strategies and informing public health policies to mitigate ACS risk.