ConformalShift: Targeted Event Reordering Against Adaptive ECG Monitoring

Transthoracic echocardiography is the reference standard for confirming structural heart disease (SHD), but first-line screening is limited by cost, workflow burden, and specialist availability. We evaluated whether open pretrained electrocardiogram (ECG) foundation models can support echo-confirmed multi-label SHD detection using the public EchoNext Mini-Model benchmark. Six echocardiography-derived abnormalities were targeted: reduced left ventricular ejection fraction, increased left ventricular wall thickness, aortic stenosis, mitral regurgitation, tricuspid regurgitation, and right ventricular systolic dysfunction. Under a common pipeline, we compared engineered ECG features with gradient boosting, end-to-end waveform learning from scratch, and transfer from open ECG foundation models. We then applied in-domain self-supervised adaptation of an ECG foundation model (ECG-FM) on EchoNext waveforms followed by selective supervised fine-tuning, and evaluated trade-offs between discrimination and adaptation cost. Adapted ECG-FM models achieved the best overall performance: peak macro-AUROC 0.8509 and macro-AUPRC 0.4297, while a parameter-efficient operating point preserved AUROC (0.8501) and attained the highest fixed-threshold macro-F1 0.3691. Late fusion with covariates did not improve threshold-independent discrimination, and evaluated LoRA, alternative backbones, and mixture-of-foundations strategies did not surpass the best adapted single-backbone models. These results indicate that for ECG-based case finding and echocardiography triage, combining target-domain self-supervised adaptation with selective supervised updating of a pretrained ECG backbone is the most effective transfer strategy.

The diagnostic value of an ECG channel depends on the model that interprets it. We test whether adaptive acquisition retains its advantage over fixed protocols when that model changes. Two policies developed with a logistic evaluator are frozen and assessed with a masked waveform ResNet1D, using exhaustive, metric-matched fixed comparators. On PTB-XL, replacing the evaluator reverses the mean adaptive advantage in negative log-likelihood and Brier score across the tested budgets, while calibration responds less uniformly. The shift persists with common fixed references and broader training-mask exposure. Training a policy against the stronger evaluator partly recovers the lost advantage. These retrospective exploratory results show that acquisition quality cannot be assessed independently of the downstream evaluator and motivate validating adaptive policies with the model intended for diagnosis.

We propose a new class of waveform foundation models that departs from conventional sequence based representations by modeling physiological time series as realizations of latent event processes. Rather than treating signals as collections of local tokens or patches, our approach assumes that clinically meaningful structure arises from temporally extended, interacting events whose boundaries and dynamics are not directly observed. To capture this structure, we introduce a self supervised learning framework that enforces consistency across stochastic segmentations and time frequency projections of the same waveform, encouraging representations that are invariant to signal level perturbations while preserving event level organization. The resulting model combines a segmentation aware encoder with a latent interaction operator that captures dependencies among inferred events, and naturally extends to multimodal settings by aligning modalities through shared event representations. Across a range of physiological benchmarks, including arrhythmia classification, hemodynamic prediction, and waveform retrieval, the proposed method improves performance, robustness, and label efficiency relative to strong sequence based baselines. These results suggest that shifting from signal centric to event centric representations provides a more appropriate inductive bias for modeling physiological dynamics and offers a complementary path to scaling foundation models in healthcare.