Xiaohan Fan

Ya Zhou, Xiaolin Diao, Yanni Huo et al.

Electrocardiogram (ECG) is one of the most important diagnostic tools in clinical applications. With the advent of advanced algorithms, various deep learning models have been adopted for ECG tasks. However, the potential of Transformer for ECG data has not been fully realized, despite their widespread success in computer vision and natural language processing. In this work, we present Masked Transformer for ECG classification (MTECG), a simple yet effective method which significantly outperforms recent state-of-the-art algorithms in ECG classification. Our approach adapts the image-based masked autoencoders to self-supervised representation learning from ECG time series. We utilize a lightweight Transformer for the encoder and a 1-layer Transformer for the decoder. The ECG signal is split into a sequence of non-overlapping segments along the time dimension, and learnable positional embeddings are added to preserve the sequential information. We construct the Fuwai dataset comprising 220,251 ECG recordings with a broad range of diagnoses, annotated by medical experts, to explore the potential of Transformer. A strong pre-training and fine-tuning recipe is proposed from the empirical study. The experiments demonstrate that the proposed method increases the macro F1 scores by 3.4%-27.5% on the Fuwai dataset, 9.9%-32.0% on the PTB-XL dataset, and 9.4%-39.1% on a multicenter dataset, compared to the alternative methods. We hope that this study could direct future research on the application of Transformer to more ECG tasks.

Ya Zhou, Tianxiang Hao, Ziyi Cai et al.

Low left ventricular ejection fraction (LEF) frequently remains undetected until progression to symptomatic heart failure, underscoring the need for scalable screening strategies. Although artificial intelligence-enabled electrocardiography (AI-ECG) has shown promise, existing approaches rely solely on end-to-end black-box models with limited interpretability or on tabular systems dependent on commercial ECG measurement algorithms with suboptimal performance. We introduced ECG-based Predictor-Driven LEF (ECGPD-LEF), a structured framework that integrates foundation model-derived diagnostic probabilities with interpretable modeling for detecting LEF from ECG. Trained on the benchmark EchoNext dataset comprising 72,475 ECG-echocardiogram pairs and evaluated in predefined independent internal (n=5,442) and external (n=16,017) cohorts, our framework achieved robust discrimination for moderate LEF (internal AUROC 88.4%, F1 64.5%; external AUROC 86.8%, F1 53.6%), consistently outperforming the official end-to-end baseline provided with the benchmark across demographic and clinical subgroups. Interpretability analyses identified high-impact predictors, including normal ECG, incomplete left bundle branch block, and subendocardial injury in anterolateral leads, driving LEF risk estimation. Notably, these predictors independently enabled zero-shot-like inference without task-specific retraining (internal AUROC 75.3-81.0%; external AUROC 71.6-78.6%), indicating that ventricular dysfunction is intrinsically encoded within structured diagnostic probability representations. This framework reconciles predictive performance with mechanistic transparency, supporting scalable enhancement through additional predictors and seamless integration with existing AI-ECG systems.

Ya Zhou, Yujie Yang, Xiaohan Fan et al.

ECG foundation models are increasingly popular due to their adaptability across various tasks. However, their clinical applicability is often limited by performance gaps compared to task-specific models, even after pre-training on large ECG datasets and fine-tuning on target data. This limitation is likely due to the lack of an effective post-training strategy. In this paper, we propose a simple yet effective post-training approach to enhance ECGFounder, a state-of-the-art ECG foundation model pre-trained on over 7 million ECG recordings. Experiments on the PTB-XL benchmark show that our approach improves the baseline fine-tuning strategy by 1.2%-3.3% in macro AUROC and 5.3%-20.9% in macro AUPRC. Additionally, our method outperforms several recent state-of-the-art approaches, including task-specific and advanced architectures. Further evaluation reveals that our method is more stable and sample-efficient compared to the baseline, achieving a 9.1% improvement in macro AUROC and a 34.9% improvement in macro AUPRC using just 10% of the training data. Ablation studies identify key components, such as stochastic depth and preview linear probing, that contribute to the enhanced performance. These findings underscore the potential of post-training strategies to improve ECG foundation models, and we hope this work will contribute to the continued development of foundation models in the ECG domain.