Foundation models for 12-lead electrocardiograms (ECGs) transfer well across clinical tasks, but the physiological knowledge encoded in their representations remains opaque. We present CADENCE, a framework that decomposes an ECG foundation model into a human-interpretable, queryable dictionary of physiological concepts. Using a BatchTopK sparse autoencoder, CADENCE factorizes Layer-6 embeddings from more than nine million ECG tokens into 8,192 sparse cardiac atoms. These atoms align better than individual dense embedding dimensions with clinical phenotypes and waveform morphology, recovering arrhythmias, conduction abnormalities, infarction and repolarization patterns, chamber and axis findings, and lead- and beat-phase-specific waveform primitives. At Layer 6, the best atoms achieve mean AUROCs of 0.88 for clinical phenotypes and 0.90 for morphology, versus 0.78 and 0.83 for the best dense dimensions. Sparse atom probes match or outperform dense probes for phenotype, morphology, and age prediction while attributing each prediction to a small set of interpretable atoms; phenotype AUROC improves from 0.93 to 0.95. Atom-space geometry recovers physiologically coherent relationships, and targeted atom ablation selectively changes frozen downstream outputs. An automated LLM pipeline generates and quantitatively validates atom descriptions by predicting held-out activations. On independent external ECG datasets, CADENCE recovers overlapping concepts and maintains consistent phenotype-prediction performance. CADENCE provides a scalable framework for discovering and auditing the physiological knowledge encoded by ECG foundation models.
Existing benchmarks for electrocardiogram foundation models primarily evaluate downstream predictive performance, providing limited insight into whether their internal representations can be faithfully decomposed, clinically interpreted, or reproduced across independent analyses. We introduce ECG-InterpBench, a benchmark designed to systematically evaluate the interpretability of ECG foundation-model representations. ECG-InterpBench uses sparse autoencoders as standardized measurement instruments and matches their capacity across models to enable controlled comparisons. We evaluate six frozen ECG foundation models across five standardized encoder depths, five matched dictionary widths, and three random seeds, producing a 450-cell interpretability atlas comprising 75 exactly matched six-model comparison blocks. The benchmark evaluates complementary dimensions of representation interpretability, including sparse reconstruction fidelity, single-feature accessibility and coverage of 49 clinically meaningful ECG measurements, and cross-seed feature reproducibility. The evaluation further quantifies patient-sampling uncertainty, depth- and seed-dependent variation, and sensitivity to the sparsity parameterization. The benchmark reveals that ECG foundation models exhibit distinct interpretability profiles. A matched replication on MIMIC-IV-ECG confirms that reconstruction fidelity and clinical accessibility identify different leading models. The benchmark is accompanied by executable evaluation code, standardized manifests, cell-level metrics, and reproducibility audits. ECG-InterpBench complements performance-centered ECG benchmarks by providing a capacity-controlled and reproducible framework for comparing ECG foundation models across distinct dimensions of representation interpretability.
Specialized foundation models are beginning to emerge in various medical subdomains, but pretraining methodologies and parametric scaling with the size of the pretraining dataset are rarely assessed systematically and in a like-for-like manner. This work focuses on foundation models for electrocardiography (ECG) data, one of the most widely captured physiological time series world-wide. We present a comprehensive assessment of pretraining methodologies, covering five different contrastive and non-contrastive self-supervised learning objectives for ECG foundation models, and investigate their scaling behavior with pretraining dataset sizes up to 11M input samples, exclusively from publicly available sources. Pretraining strategy has a meaningful and consistent impact on downstream performance, with contrastive predictive coding (slightly ahead of JEPA) yielding the most transferable representations across diverse clinical tasks. Scaling pretraining data continues to yield meaningful improvements up to 11M samples for most objectives. We also compare model architectures across all pretraining methodologies and find evidence for a clear superiority of structured state space models compared to transformers and CNN models. We hypothesize that the strong inductive biases of structured state space models, rather than pretraining scale alone, are the primary driver of effective ECG representation learning, with important implications for future foundation model development in this and potentially other physiological signal domains.
Point-of-care cardiac devices such as smartwatches and handheld ECG recorders typically capture 1--2 leads, yet existing ECG foundation models are architecturally constrained to fixed 12-lead inputs, degrading or failing under these reduced configurations. We introduce LAEF (Lead-Agnostic ECG Foundation), a 7M-parameter ECG foundation model that can natively process any lead subset without zero-padding or architectural modification. LAEF represents ECGs as variable-size spatiotemporal graphs with physiologically motivated intra- and inter-lead connectivity, processed by a Graph Attention Network that scales naturally with active lead count.Pre-trained on 9.2M 12-lead ECGs via masked node modelling with stochastic lead sampling, LAEF learns representations robust to lead configuration. Across 18 downstream datasets, LAEF is on par with specialized 12-lead baselines over 12× larger at full lead availability. Under direct point-of-care-oriented diagnostics (1--2 leads), it outperforms all zero-padded alternatives on 17 out of 18 datasets with with a single randomly sampled lead and on 14 out of 18 with 2 leads, with an average AUROC gain of +3.2 points. Representation analysis links this advantage to architectural lead-agnosticism, and a lead-importance study across 164 cardiovascular conditions shows population-level performance is stable across single standard input leads while still recovering established clinically lead-condition associations.