PPGFlowECG: Latent Rectified Flow with Cross-Modal Encoding for PPG-Guided ECG Generation and Cardiovascular Disease Detection

Electrocardiography (ECG) is the clinical standard for cardiac assessment but requires dedicated hardware that does not scale to daily-life monitoring. Photoplethysmography (PPG) is ubiquitous in wearables but lacks ECG-specific diagnostic morphology and is corrupted by motion and sensor noise. PPG-to-ECG generation aims to bridge this gap by recovering electrical morphology and timing from peripheral pulse signals. However, existing methods largely rely on statistical alignment and data-driven generation. They fail to explicitly structure the latent space around physiology-aware electro-hemodynamic factors and lack constraints from forward physiological dynamics. To address these challenges, we propose PG-LRF, a physiology-guided latent rectified flow framework. PG-LRF introduces an electro-hemodynamic simulator that co-models ECG and PPG through shared cardiac phase dynamics. Guided by this simulator, a Physiology-Aware AutoEncoder learns a structured electro-hemodynamic latent space. Then we integrate this simulator guidance into a PPG-conditioned latent rectified flow, enforcing ECG-side morphology consistency and ECG-to-PPG forward hemodynamic consistency during generative transport. Experiments on the large-scale MC-MED dataset demonstrate that PG-LRF significantly improves PPG-to-ECG generation and downstream cardiovascular disease classification, proving its ability to generate ECGs that are both signal-faithful and physiologically plausible under the ECG-to-PPG hemodynamic pathway

Continuous cardiac monitoring outside clinical settings requires signals that are both informative and practical to collect during daily life. Electrocardiography (ECG) provides rich information about cardiac rhythm and waveform morphology, while wearable photoplethysmography (PPG) is easier to acquire continuously but is only an indirect cardiovascular measurement and is highly sensitive to motion. We present BeatFlow-ECG, a conditional rectified-flow model for reconstructing single-channel ECG from synchronized PPG and inertial measurements. BeatFlow-ECG models reconstruction as conditional transport from noise to ECG using a convolutional encoder-decoder with a transformer bottleneck and explicit flow-time conditioning. Motion information is incorporated through IMU-derived conditioning features, motion-dependent loss weighting, and an easy-to-hard training curriculum. We evaluate the model under leave-one-subject-out protocols on PPG-DaLiA and WESAD. BeatFlow-ECG achieves the best results among the evaluated deterministic, adversarial, and diffusion-based baselines across all reported waveform and beat-timing metrics, with Pearson correlations of 0.983 and 0.986 and R-peak F1 scores of 0.946 and 0.955, respectively. Compared with Conditional DDPM-1D, L1 error decreases from 0.085 to 0.062 on PPG-DaLiA and from 0.074 to 0.055 on WESAD. Additional analyses on PPG-DaLiA show higher correlation in fixed R-peak-relative waveform regions and lower reconstruction error across low-, medium-, and high-motion subsets.

Cardiovascular disease remains the leading cause of global mortality, yet scalable cardiac monitoring is hindered by the gap between diagnostic-rich ECG and ubiquitous wearable PPG. Bridging this gap requires representations that are compact, transferable across modalities and devices, and deployable without task-specific retraining. Here we introduce biosignal fingerprints: compact latent representations of cardiovascular state derived from a cross-modal foundation model, the Multi-modal Masked Autoencoder (M2AE), trained on over 3.4 million paired ECG and PPG signals. M2AE integrates modality-specific encoders with a shared bottleneck and dual decoders, jointly optimized using reconstruction and cross-modal contrastive objectives, yielding generalizable fingerprints that retain intra- and inter-modality features. Like a biometric fingerprint, these representations uniquely encode an individual's cardiovascular state in a modality-agnostic, privacy-preserving form reusable across clinical tasks without exposing raw waveform data or requiring model retraining. Across 7 downstream tasks, spanning cross-modal reconstruction, cardiovascular disease classification, hypertension detection, mortality prediction, and demographic inference, biosignal fingerprints achieve competitive or superior performance compared to leading domain-specialist foundation models in frozen settings, including an AUROC of 0.974 for five-class CVD classification and 0.877 for hypertension detection, with a maximum improvement of 27.7% in AUROC across 5 classification tasks. Critically, strong performance is maintained with only a single modality, enabling deployment in resource-constrained, single-sensor environments typical of real-world wearable monitoring, with direct implications for continuous cardiovascular monitoring across clinical and consumer health settings.