Can Large Language Models Reliably Extract Physiology Index Values from Coronary Angiography Reports?

Invasive coronary angiography (CAG) is the gold standard for diagnosing coronary artery disease, but interpretation varies substantially among observers. Existing AI systems can improve consistency but lack auditable decision processes and are limited in comprehensive open-ended assessment, undermining clinician trust and clinical adoption readiness. We developed CARDEA, a unified large vision-language model that serves as the inference core of a CAG pipeline. It was trained solely on public datasets and closed-ended tasks in three stages: visual feature alignment, a self-distilled Chain-of-Box (CoB) cold start, and reinforcement learning with verifiable rewards (RLVR) with a CoB reward encouraging bounding-box use in the reasoning trace. We assessed its two study-level diagnoses, dominance classification and complexity assessment, against a dedicated classifier and two interventional cardiologists. Report generation was excluded from training and evaluated zero-shot across stages on an external cohort using vessel-severity macro-$F_1$. CARDEA trailed the classifier on in-distribution dominance but drew level under domain shift (accuracy, 0.91 [95% confidence interval (CI), 0.86 to 0.95]) and was comparable to the cardiologists on complexity assessment (accuracy, 0.90 [CI, 0.82 to 0.97]). Only RLVR improved zero-shot report generation, raising its vessel-severity macro-$F_1$ (0.686 [CI, 0.664 to 0.707]) above the untuned base model (0.513) and over twice the always-normal floor (0.312). CARDEA runs an end-to-end CAG pipeline from raw multi-view videos through keyframe selection to study-level diagnosis while exposing auditable spatial evidence behind its conclusions. RLVR on verifiable closed-ended tasks surfaced open-ended reporting ability that supervised imitation did not. Clinical use requires prospective validation against expert cardiologists.

Photoplethysmography (PPG) is widely recorded by clinical monitors and consumer wearables, providing a scalable source of continuous physiological information. These recordings offer an opportunity for physiological assessment at scale, but realizing this potential requires models to learn from both signal-derived physiological supervision and broader clinical context captured in electronic health records (EHRs). This involves aligning information spanning local observations, care events, and entire visits with PPG representations at corresponding temporal scales. However, existing PPG foundation models primarily rely on task-specific prediction heads, while the medical knowledge of large language models does not necessarily translate into waveform understanding. To bridge this gap, we introduce PPG-LM, the first PPG-language model family to learn physiological representations from both signal-derived supervision and broader clinical context captured in EHRs. To construct clinically grounded captions, we develop an automatic captioning pipeline that generates segment-, event-, and visit-level descriptions from signal measurements and structured EHR records. We then learn from these pairs through a two-stage framework that first establishes segment-language correspondence through contrastive learning and waveform-conditioned captioning, then extends alignment to events and visits through time-aware aggregation and temporal statement matching. Pretrained on approximately 73k hours of PPG, PPG-LM supports language-based recognition, cross-modal retrieval, and segment captioning. Experiments on MC-MED, MIMIC-III, and VitalDB show improved retrieval and caption factuality over language-model baselines and gains over PPG and time-series foundation models on multiple clinical prediction tasks.

Coronary angiography is the reference standard for evaluating coronary artery disease, yet visual interpretation remains variable between readers. Existing artificial intelligence methods typically analyze single frames or projections and focus mainly on stenosis, limiting comprehensive coronary assessment. We present DeepCORO-CLIP, a multi-view foundation model trained with video-text contrastive learning on 203,808 angiography videos from 28,117 patients across 32,473 studies at the Montreal Heart Institute and externally validated on 4,249 studies from the University of California, San Francisco. DeepCORO-CLIP integrates multiple projections with attention-based pooling for study-level assessment across diagnostic, prognostic, and disease progression tasks. For significant stenosis detection, the model achieved an AUROC of 0.888 internally and 0.89 on external validation. Mean absolute error against core laboratory quantitative coronary angiography was 13.6%, lower than clinical reports at 19.0%. The model also performed strongly for chronic total occlusion, intracoronary thrombus, and coronary calcification detection. Transfer learning enabled prediction of one-year major adverse cardiovascular events with AUROC 0.79 and estimation of left ventricular ejection fraction with mean absolute error 7.3%. Embeddings also captured disease progression across serial examinations. With a mean inference time of 4.2 seconds in hospital deployment, DeepCORO-CLIP provides a foundation for automated coronary angiography interpretation at the point of care. Code, sample data, model weights, and deployment infrastructure are publicly released.