Harmonized Interpretable ECG Waveform Features for Robust Cross-Dataset Clinical Prediction

Electrocardiography (ECG) is central to cardiovascular care, but conventional AI models are often restricted to common arrhythmias and may generalize poorly across populations or clinically subtle diseases. We developed ECG Contrastive Language-Image Pre-training (ECGCLIP), a signal-language contrastive learning framework that aligns ECG waveforms with expert diagnostic reports. ECGCLIP was pre-trained on 2,837,962 ECG studies from 1,324,856 patients and evaluated on a held-out internal test set plus nine independent external cohorts comprising about 1.5 million ECGs. Evaluation covered 89 downstream tasks, including 45 ECG diagnoses, 39 echocardiographic targets, and 5 rare cardiac diseases, using PRAUC as the primary metric. ECGCLIP consistently improved performance over random initialization and Merl-R18 baselines. On the internal test set, ECGCLIP-R34 achieved strong performance for atrial fibrillation (PRAUC 0.900) and ST-segment elevation myocardial infarction (PRAUC 0.383), with robust generalization across all external cohorts. It also improved low-prevalence and diagnostically elusive diseases, including Ebstein anomaly, constrictive pericarditis, dextrocardia, and cardiac amyloidosis, with internal PRAUC values of 0.253, 0.175, 0.121, and 0.201, respectively. ECGCLIP was data efficient, matching or exceeding full-dataset baseline performance with only 10% of training data. Feature visualization and saliency analysis suggested clinically meaningful representations aligned with established electrocardiographic criteria. These findings indicate that large-scale ECG-report contrastive pre-training can expand routine ECG interpretation beyond common arrhythmias toward broad cardiovascular assessment and opportunistic screening of echocardiographic and rare conditions.

Foundation models have recently emerged as a powerful paradigm for learning transferable representations from large scale biomedical data, yet existing approaches for physiological waveforms primarily optimize reconstruction or forecasting objectives that do not explicitly preserve clinically meaningful waveform morphology. Electrocardiograms (ECGs) and pulse oximetry (SpO2) waveforms encode rich cardiovascular and hemodynamic information through their morphological structure. In this work, we introduce MorphologyFM, a multimodal foundation model pretrained on paired ECG and SpO2 waveforms from the MIMIC critical care database using a morphology aware self supervised learning objective. MorphologyFM combines morphology guided masking, cross modal representation learning, and contrastive latent alignment to learn representations that capture clinically relevant physiological structure without requiring manual annotations. We evaluate MorphologyFM across multiple downstream prediction tasks, including arrhythmia classification, hypoxemia prediction, mortality prediction, and length of stay estimation, demonstrating consistent improvements over representative self supervised learning methods, including Masked Autoencoders (MAE), contrastive learning, Barlow Twins, and Joint Embedding Predictive Architectures (JEPA). Furthermore, we show that jointly modeling ECG and SpO2 waveforms produces more transferable representations than single modality pretraining. Our results establish waveform morphology as a powerful inductive bias for self supervised physiological representation learning and introduce MorphologyFM as a general purpose foundation model for continuous physiological monitoring.

While Deep Learning (DL) enhances automated electrocardiogram (ECG) analysis, clinical deployment is hindered by class imbalance and the generalization gap. This paper presents HeartBeatAI, a deep learning framework combining domain generalization, multi-scale feature aggregation, and clinical explainability for robust 12-lead ECG classification. Moving beyond image-based paradigms, HeartBeatAI integrates a Squeeze-and-Excitation (SE) ResNet to isolate diagnostic leads alongside a Multi-Layer Concentration Pipeline to capture macro-rhythm and micro-morphological anomalies. To mitigate domain shift, the framework employs MixStyle regularization and Label Smoothing. Rigorous benchmarking across four large-scale datasets using intra-source and Leave-One-Domain-Out (LODO) protocols demonstrates high performance (98% Macro F1-score) under intra-source conditions. However, LODO evaluations reveal significant degradation in detecting rare anomalies, highlighting a persistent challenge in cross-institutional deployment.