Dual-Phase Cross-Modal Contrastive Learning for CMR-Guided ECG Representations for Cardiovascular Disease Assessment

Cardiac magnetic resonance imaging (CMR) offers detailed evaluation of cardiac structure and function, but its limited accessibility restricts use to selected patient populations. In contrast, the electrocardiogram (ECG) is ubiquitous and inexpensive, and provides rich information on cardiac electrical activity and rhythm, yet offers limited insight into underlying cardiac structure and mechanical function. To address this, we introduce a contrastive learning framework that improves the extraction of clinically relevant cardiac phenotypes from ECG by learning from paired ECG-CMR data. Our approach aligns ECG representations with 3D CMR volumes at end-diastole (ED) and end-systole (ES), with a dual-phase contrastive loss to anchor each ECG jointly with both cardiac phases in a shared latent space. Unlike prior methods limited to 2D CMR representations with or without a temporal component, our framework models 3D anatomy at both ED and ES phases as distinct latent representations, enabling flexible disentanglement of structural and functional cardiac properties. Using over 34,000 ECG-CMR pairs from the UK Biobank, we demonstrate improved extraction of image-derived phenotypes from ECG, particularly for functional parameters ($\uparrow$ 9.2\%), while improvements in clinical outcome prediction remained modest ($\uparrow$ 0.7\%). This strategy could enable scalable and cost-effective extraction of image-derived traits from ECG. The code for this research is publicly available.

Task- and Metric-Specific Signal Quality Indices for Medical Time Series

Medical time series such as electrocardiograms (ECGs) and photoplethysmograms (PPGs) are frequently affected by measurement artifacts due to challenging acquisition environments, such as in ambulances and during routine daily activities. Since automated algorithms for analyzing such signals increasingly inform clinically relevant decisions, identifying signal segments on which these algorithms may produce unreliable outputs is of critical importance. Signal quality indices (SQIs) are commonly used for this purpose. However, most existing SQIs are task agnostic and do not account for the specific algorithm and performance metric used downstream. In this work, we formalize signal quality as a task- and metric-dependent concept and propose a perturbation-based SQI (pSQI) that aims to detect an algorithm's performance degradation on an input signal with respect to a metric. The pSQI is defined as the worst-case value of the performance metric under an additive, colored Gaussian noise perturbation with a lower-bounded signal-to-noise ratio. We introduce formal requirements for task- and metric-specific SQIs, including monotonicity of the metric in expectation and maximal separation under thresholding. Experiments on R-peak detection and atrial fibrillation classification benchmarks demonstrate that the proposed pSQI consistently outperforms existing feature- and deep learning-based SQIs in identifying unreliable inputs without requiring training.

Contrastive Learning for Multi Label ECG Classification with Jaccard Score Based Sigmoid Loss

Recent advances in large language models (LLMs) have enabled the development of multimodal medical AI. While models such as MedGemini achieve high accuracy on VQA tasks like USMLE MM, their performance on ECG based tasks remains limited, and some models, such as MedGemma, do not support ECG data at all. Interpreting ECGs is inherently challenging, and diagnostic accuracy can vary depending on the interpreter's experience. Although echocardiography provides rich diagnostic information, it requires specialized equipment and personnel, limiting its availability. In this study, we focus on constructing a robust ECG encoder for multimodal pretraining using real world hospital data. We employ SigLIP, a CLIP based model with a sigmoid based loss function enabling multi label prediction, and introduce a modified loss function tailored to the multi label nature of ECG data. Experiments demonstrate that incorporating medical knowledge in the language model and applying the modified loss significantly improve multi label ECG classification. To further enhance performance, we increase the embedding dimensionality and apply random cropping to mitigate data drift. Finally, per label analysis reveals which ECG findings are easier or harder to predict. Our study provides a foundational framework for developing medical models that utilize ECG data.

ECG-IMN: Interpretable Mesomorphic Neural Networks for 12-Lead Electrocardiogram Interpretation

Deep learning has achieved expert-level performance in automated electrocardiogram (ECG) diagnosis, yet the "black-box" nature of these models hinders their clinical deployment. Trust in medical AI requires not just high accuracy but also transparency regarding the specific physiological features driving predictions. Existing explainability methods for ECGs typically rely on post-hoc approximations (e.g., Grad-CAM and SHAP), which can be unstable, computationally expensive, and unfaithful to the model's actual decision-making process. In this work, we propose the ECG-IMN, an Interpretable Mesomorphic Neural Network tailored for high-resolution 12-lead ECG classification. Unlike standard classifiers, the ECG-IMN functions as a hypernetwork: a deep convolutional backbone generates the parameters of a strictly linear model specific to each input sample. This architecture enforces intrinsic interpretability, as the decision logic is mathematically transparent and the generated weights (W) serve as exact, high-resolution feature attribution maps. We introduce a transition decoder that effectively maps latent features to sample-wise weights, enabling precise localization of pathological evidence (e.g., ST-elevation, T-wave inversion) in both time and lead dimensions. We evaluate our approach on the PTB-XL dataset for classification tasks, demonstrating that the ECG-IMN achieves competitive predictive performance (AUROC comparable to black-box baselines) while providing faithful, instance-specific explanations. By explicitly decoupling parameter generation from prediction execution, our framework bridges the gap between deep learning capability and clinical trustworthiness, offering a principled path toward "white-box" cardiac diagnostics.

PTB-XL-Image-17K: A Large-Scale Synthetic ECG Image Dataset with Comprehensive Ground Truth for Deep Learning-Based Digitization

Electrocardiogram (ECG) digitization-converting paper-based or scanned ECG images back into time-series signals-is critical for leveraging decades of legacy clinical data in modern deep learning applications. However, progress has been hindered by the lack of large-scale datasets providing both ECG images and their corresponding ground truth signals with comprehensive annotations. We introduce PTB-XL-Image-17K, a complete synthetic ECG image dataset comprising 17,271 high-quality 12-lead ECG images generated from the PTB-XL signal database. Our dataset uniquely provides five complementary data types per sample: (1) realistic ECG images with authentic grid patterns and annotations (50% with visible grid, 50% without), (2) pixel-level segmentation masks, (3) ground truth time-series signals, (4) bounding box annotations in YOLO format for both lead regions and lead name labels, and (5) comprehensive metadata including visual parameters and patient information. We present an open-source Python framework enabling customizable dataset generation with controllable parameters including paper speed (25/50 mm/s), voltage scale (5/10 mm/mV), sampling rate (500 Hz), grid appearance (4 colors), and waveform characteristics. The dataset achieves 100% generation success rate with an average processing time of 1.35 seconds per sample. PTB-XL-Image-17K addresses critical gaps in ECG digitization research by providing the first large-scale resource supporting the complete pipeline: lead detection, waveform segmentation, and signal extraction with full ground truth for rigorous evaluation. The dataset, generation framework, and documentation are publicly available at https://github.com/naqchoalimehdi/PTB-XL-Image-17K and https://doi.org/10.5281/zenodo.18197519.

Orientation-Robust Latent Motion Trajectory Learning for Annotation-free Cardiac Phase Detection in Fetal Echocardiography

Fetal echocardiography is essential for detecting congenital heart disease (CHD), facilitating pregnancy management, optimized delivery planning, and timely postnatal interventions. Among standard imaging planes, the four-chamber (4CH) view provides comprehensive information for CHD diagnosis, where clinicians carefully inspect the end-diastolic (ED) and end-systolic (ES) phases to evaluate cardiac structure and motion. Automated detection of these cardiac phases is thus a critical component toward fully automated CHD analysis. Yet, in the absence of fetal electrocardiography (ECG), manual identification of ED and ES frames remains a labor-intensive bottleneck. We present ORBIT (Orientation-Robust Beat Inference from Trajectories), a self-supervised framework that identifies cardiac phases without manual annotations under various fetal heart orientation. ORBIT employs registration as self-supervision task and learns a latent motion trajectory of cardiac deformation, whose turning points capture transitions between cardiac relaxation and contraction, enabling accurate and orientation-robust localization of ED and ES frames across diverse fetal positions. Trained exclusively on normal fetal echocardiography videos, ORBIT achieves consistent performance on both normal (MAE = 1.9 frames for ED and 1.6 for ES) and CHD cases (MAE = 2.4 frames for ED and 2.1 for ES), outperforming existing annotation-free approaches constrained by fixed orientation assumptions. These results highlight the potential of ORBIT to facilitate robust cardiac phase detection directly from 4CH fetal echocardiography.

ECG-R1: Protocol-Guided and Modality-Agnostic MLLM for Reliable ECG Interpretation

Electrocardiography (ECG) serves as an indispensable diagnostic tool in clinical practice, yet existing multimodal large language models (MLLMs) remain unreliable for ECG interpretation, often producing plausible but clinically incorrect analyses. To address this, we propose ECG-R1, the first reasoning MLLM designed for reliable ECG interpretation via three innovations. First, we construct the interpretation corpus using \textit{Protocol-Guided Instruction Data Generation}, grounding interpretation in measurable ECG features and monograph-defined quantitative thresholds and diagnostic logic. Second, we present a modality-decoupled architecture with \textit{Interleaved Modality Dropout} to improve robustness and cross-modal consistency when either the ECG signal or ECG image is missing. Third, we present \textit{Reinforcement Learning with ECG Diagnostic Evidence Rewards} to strengthen evidence-grounded ECG interpretation. Additionally, we systematically evaluate the ECG interpretation capabilities of proprietary, open-source, and medical MLLMs, and provide the first quantitative evidence that severe hallucinations are widespread, suggesting that the public should not directly trust these outputs without independent verification. Code and data are publicly available at \href{https://github.com/PKUDigitalHealth/ECG-R1}{here}, and an online platform can be accessed at \href{http://ai.heartvoice.com.cn/ECG-R1/}{here}.

Med-MMFL: A Multimodal Federated Learning Benchmark in Healthcare

Federated learning (FL) enables collaborative model training across decentralized medical institutions while preserving data privacy. However, medical FL benchmarks remain scarce, with existing efforts focusing mainly on unimodal or bimodal modalities and a limited range of medical tasks. This gap underscores the need for standardized evaluation to advance systematic understanding in medical MultiModal FL (MMFL). To this end, we introduce Med-MMFL, the first comprehensive MMFL benchmark for the medical domain, encompassing diverse modalities, tasks, and federation scenarios. Our benchmark evaluates six representative state-of-the-art FL algorithms, covering different aggregation strategies, loss formulations, and regularization techniques. It spans datasets with 2 to 4 modalities, comprising a total of 10 unique medical modalities, including text, pathology images, ECG, X-ray, radiology reports, and multiple MRI sequences. Experiments are conducted across naturally federated, synthetic IID, and synthetic non-IID settings to simulate real-world heterogeneity. We assess segmentation, classification, modality alignment (retrieval), and VQA tasks. To support reproducibility and fair comparison of future multimodal federated learning (MMFL) methods under realistic medical settings, we release the complete benchmark implementation, including data processing and partitioning pipelines, at https://github.com/bhattarailab/Med-MMFL-Benchmark .

Verification and Identification in ECG biometric on large-scale

This work studies electrocardiogram (ECG) biometrics at large scale, directly addressing a critical gap in the literature: the scarcity of large-scale evaluations with operational metrics and protocols that enable meaningful standardization and comparison across studies. We show that identity information is already present in tabular representations (fiducial features): even a simple MLP-based embedding network yields non-trivial performance, establishing a strong baseline before waveform modeling. We then adopt embedding-based deep learning models (ArcFace), first on features and then on ECG waveforms, showing a clear performance jump when moving from tabular inputs to waveforms, and a further gain with larger training sets and consistent normalization across train/val/test. On a large-scale test set, verification achieves high TAR at strict FAR thresholds (TAR=0.908 @ FAR=1e-3; TAR=0.820 @ FAR=1e-4) with EER=2.53\% (all-vs-all); closed-set identification yields Rank@1=0.812 and Rank@10=0.910. In open-set, a two-stage pipeline (top-$K$ shortlist on embeddings + re-ranking) reaches DIR@FAR up to 0.976 at FAR=1e-3 and 1e-4. Overall, the results show that ECG carries a measurable individual signature and that large-scale testing is essential to obtain realistic, comparable metrics. The study provides an operationally grounded benchmark that helps standardize evaluation across protocols.

Prenatal Stress Detection from Electrocardiography Using Self-Supervised Deep Learning: Development and External Validation

Prenatal psychological stress affects 15-25% of pregnancies and increases risks of preterm birth, low birth weight, and adverse neurodevelopmental outcomes. Current screening relies on subjective questionnaires (PSS-10), limiting continuous monitoring. We developed deep learning models for stress detection from electrocardiography (ECG) using the FELICITy 1 cohort (151 pregnant women, 32-38 weeks gestation). A ResNet-34 encoder was pretrained via SimCLR contrastive learning on 40,692 ECG segments per subject. Multi-layer feature extraction enabled binary classification and continuous PSS prediction across maternal (mECG), fetal (fECG), and abdominal ECG (aECG). External validation used the FELICITy 2 RCT (28 subjects, different ECG device, yoga intervention vs. control). On FELICITy 1 (5-fold CV): mECG 98.6% accuracy (R2=0.88, MAE=1.90), fECG 99.8% (R2=0.95, MAE=1.19), aECG 95.5% (R2=0.75, MAE=2.80). External validation on FELICITy 2: mECG 77.3% accuracy (R2=0.62, MAE=3.54, AUC=0.826), aECG 63.6% (R2=0.29, AUC=0.705). Signal quality-based channel selection outperformed all-channel averaging (+12% R2 improvement). Mixed-effects models detected a significant intervention response (p=0.041). Self-supervised deep learning on pregnancy ECG enables accurate, objective stress assessment, with multi-layer feature extraction substantially outperforming single embedding approaches.