Shijia Geng

Wenrui Zhang, Ling Yang, Shijia Geng et al.

Unsupervised/self-supervised representation learning in time series is critical since labeled samples are usually scarce in real-world scenarios. Existing approaches mainly leverage the contrastive learning framework, which automatically learns to understand the similar and dissimilar data pairs. Nevertheless, they are restricted to the prior knowledge of constructing pairs, cumbersome sampling policy, and unstable performances when encountering sampling bias. Also, few works have focused on effectively modeling across temporal-spectral relations to extend the capacity of representations. In this paper, we aim at learning representations for time series from a new perspective and propose Cross Reconstruction Transformer (CRT) to solve the aforementioned problems in a unified way. CRT achieves time series representation learning through a cross-domain dropping-reconstruction task. Specifically, we transform time series into the frequency domain and randomly drop certain parts in both time and frequency domains. Dropping can maximally preserve the global context compared to cropping and masking. Then a transformer architecture is utilized to adequately capture the cross-domain correlations between temporal and spectral information through reconstructing data in both domains, which is called Dropped Temporal-Spectral Modeling. To discriminate the representations in global latent space, we propose Instance Discrimination Constraint to reduce the mutual information between different time series and sharpen the decision boundaries. Additionally, we propose a specified curriculum learning strategy to optimize the CRT, which progressively increases the dropping ratio in the training process.

Deyun Zhang, Shijia Geng, Yang Zhou et al.

The artificial intelligence (AI) system has achieved expert-level performance in electrocardiogram (ECG) signal analysis. However, in underdeveloped countries or regions where the healthcare information system is imperfect, only paper ECGs can be provided. Analysis of real-world ECG images (photos or scans of paper ECGs) remains challenging due to complex environments or interference. In this study, we present an AI system developed to detect and screen cardiac abnormalities (CAs) from real-world ECG images. The system was evaluated on a large dataset of 52,357 patients from multiple regions and populations across the world. On the detection task, the AI system obtained area under the receiver operating curve (AUC) of 0.996 (hold-out test), 0.994 (external test 1), 0.984 (external test 2), and 0.979 (external test 3), respectively. Meanwhile, the detection results of AI system showed a strong correlation with the diagnosis of cardiologists (cardiologist 1 (R=0.794, p<1e-3), cardiologist 2 (R=0.812, p<1e-3)). On the screening task, the AI system achieved AUCs of 0.894 (hold-out test) and 0.850 (external test). The screening performance of the AI system was better than that of the cardiologists (AI system (0.846) vs. cardiologist 1 (0.520) vs. cardiologist 2 (0.480)). Our study demonstrates the feasibility of an accurate, objective, easy-to-use, fast, and low-cost AI system for CA detection and screening. The system has the potential to be used by healthcare professionals, caregivers, and general users to assess CAs based on real-world ECG images.

Jiahao Shao, Shijia Geng, Zhaoji Fu et al.

In clinics, doctors rely on electrocardiograms (ECGs) to assess severe cardiac disorders. Owing to the development of technology and the increase in health awareness, ECG signals are currently obtained by using medical and commercial devices. Deep neural networks (DNNs) can be used to analyze these signals because of their high accuracy rate. However, researchers have found that adversarial attacks can significantly reduce the accuracy of DNNs. Studies have been conducted to defend ECG-based DNNs against traditional adversarial attacks, such as projected gradient descent (PGD), and smooth adversarial perturbation (SAP) which targets ECG classification; however, to the best of our knowledge, no study has completely explored the defense against adversarial attacks targeting ECG classification. Thus, we did different experiments to explore the effects of defense methods against white-box adversarial attack and black-box adversarial attack targeting ECG classification, and we found that some common defense methods performed well against these attacks. Besides, we proposed a new defense method called Adversarial Distillation Training (ADT) which comes from defensive distillation and can effectively improve the generalization performance of DNNs. The results show that our method performed more effectively against adversarial attacks targeting on ECG classification than the other baseline methods, namely, adversarial training, defensive distillation, Jacob regularization, and noise-to-signal ratio regularization. Furthermore, we found that our method performed better against PGD attacks with low noise levels, which means that our method has stronger robustness.

Donglin Xie, Qingshuo Zhao, Jingyu Wang et al.

Sleep disturbances are tightly linked to cardiovascular risk, yet polysomnography (PSG)-the clinical reference standard-remains resource-intensive and poorly suited for multi-night, home-based, and large-scale screening. Single-lead electrocardiography (ECG), already ubiquitous in Holter and patch-based devices, enables comfortable long-term acquisition and encodes sleep-relevant physiology through autonomic modulation and cardiorespiratory coupling. Here, we present a proof-of-concept Holter-to-Sleep framework that, using single-lead ECG as the sole input, jointly supports overnight sleep phenotyping and Holter-grade cardiac phenotyping within the same recording, and further provides an explicit analytic pathway for scalable cardio-sleep association studies. The framework is developed and validated on a pooled multi-center PSG sample of 10,439 studies spanning four public cohorts, with independent external evaluation to assess cross-cohort generalizability, and additional real-world feasibility assessment using overnight patch-ECG recordings via objective-subjective consistency analysis. This integrated design enables robust extraction of clinically meaningful overnight sleep phenotypes under heterogeneous populations and acquisition conditions, and facilitates systematic linkage between ECG-derived sleep metrics and arrhythmia-related Holter phenotypes. Collectively, the Holter-to-Sleep paradigm offers a practical foundation for low-burden, home-deployable, and scalable cardio-sleep monitoring and research beyond traditional PSG-centric workflows.

Gongzheng Tang, Qinghao Zhao, Guangkun Nie et al.

Hyperkalemia is a life-threatening electrolyte disorder that is common in patients with chronic kidney disease and heart failure, yet frequent monitoring remains difficult outside hospital settings. We developed and validated Pocket-K, a single-lead AI-ECG system initialized from the ECGFounder foundation model for non-invasive hyperkalemia screening and handheld deployment. In this multicentre observational study using routinely collected clinical ECG and laboratory data, 34,439 patients contributed 62,290 ECG--potassium pairs. Lead I data were used to fine-tune the model. Data from Peking University People's Hospital were divided into development and temporal validation sets, and data from The Second Hospital of Tianjin Medical University served as an independent external validation set. Hyperkalemia was defined as venous serum potassium > 5.5 mmol/L. Pocket-K achieved AUROCs of 0.936 in internal testing, 0.858 in temporal validation, and 0.808 in external validation. For KDIGO-defined moderate-to-severe hyperkalemia (serum potassium >= 6.0 mmol/L), AUROCs increased to 0.940 and 0.861 in the temporal and external sets, respectively. External negative predictive value exceeded 99.3%. Model-predicted high risk below the hyperkalemia threshold was more common in patients with chronic kidney disease and heart failure. A handheld prototype enabled near-real-time inference, supporting future prospective evaluation in native handheld and wearable settings.

Sumei Fan, Deyun Zhang, Yue Wang et al.

Accurate, continuous out-of-hospital electrocardiogram (ECG) parameter measurement is vital for real-time cardiac health monitoring and telemedicine. On-device computation of single-lead ECG parameters enables timely assessment without reliance on centralized data processing, advancing personalized, ubiquitous cardiac care-yet comprehensive validation across heterogeneous real-world populations remains limited. This study validated the on-device algorithm FeatureDB (https://github.com/PKUDigitalHealth/FeatureDB) using two datasets: HeartVoice-ECG-lite (369 participants with single-lead ECGs annotated by two physicians) and PTB-XL/PTB-XL+ (21,354 patients with 12-lead ECGs and physicians' diagnostic annotations). FeatureDB computed PR, QT, and QTc intervals, with accuracy evaluated against physician annotations via mean absolute error (MAE), correlation analysis, and Bland-Altman analysis. Diagnostic performance for first-degree atrioventricular block (AVBI, PR-based) and long QT syndrome (LQT, QTc-based) was benchmarked against commercial 12-lead systems (12SL, Uni-G) and open-source algorithm Deli, using AUC, accuracy, sensitivity, and specificity. Results showed high concordance with expert annotations (Pearson correlations: 0.836-0.960), MAEs matching inter-observer variability, and minimal bias. AVBI AUC reached 0.787 (12SL: 0.859; Uni-G: 0.812; Deli: 0.501); LQT AUC was 0.684 (12SL: 0.716; Uni-G: 0.605; Deli: 0.569)-comparable to commercial tools and superior to open-source alternatives. FeatureDB delivers physician-level parameter accuracy and commercial-grade abnormality detection via single-lead devices, supporting scalable telemedicine, decentralized cardiac screening, and continuous monitoring in community and outpatient settings.

Guangkun Nie, Jiabao Zhu, Gongzheng Tang et al.

Photoplethysmography (PPG) is a highly promising device due to its advantages in portability, user-friendly operation, and non-invasive capabilities to measure a wide range of physiological information. Recent advancements in deep learning have demonstrated remarkable outcomes by leveraging PPG signals for tasks related to personal health management and other multifaceted applications. In this review, we systematically reviewed papers that applied deep learning models to process PPG data between January 1st of 2017 and July 31st of 2023 from Google Scholar, PubMed and Dimensions. Each paper is analyzed from three key perspectives: tasks, models, and data. We finally extracted 193 papers where different deep learning frameworks were used to process PPG signals. Based on the tasks addressed in these papers, we categorized them into two major groups: medical-related, and non-medical-related. The medical-related tasks were further divided into seven subgroups, including blood pressure analysis, cardiovascular monitoring and diagnosis, sleep health, mental health, respiratory monitoring and analysis, blood glucose analysis, as well as others. The non-medical-related tasks were divided into four subgroups, which encompass signal processing, biometric identification, electrocardiogram reconstruction, and human activity recognition. In conclusion, significant progress has been made in the field of using deep learning methods to process PPG data recently. This allows for a more thorough exploration and utilization of the information contained in PPG signals. However, challenges remain, such as limited quantity and quality of publicly available databases, a lack of effective validation in real-world scenarios, and concerns about the interpretability, scalability, and complexity of deep learning models. Moreover, there are still emerging research areas that require further investigation.

Yongfan Lai, Jiabo Chen, Deyun Zhang et al.

Heart disease remains a significant threat to human health. As a non-invasive diagnostic tool, the electrocardiogram (ECG) is one of the most widely used methods for cardiac screening. However, the scarcity of high-quality ECG data, driven by privacy concerns and limited medical resources, creates a pressing need for effective ECG signal generation. Existing approaches for generating ECG signals typically rely on small training datasets, lack comprehensive evaluation frameworks, and overlook potential applications beyond data augmentation. To address these challenges, we propose DiffuSETS, a novel framework capable of generating ECG signals with high semantic alignment and fidelity. DiffuSETS accepts various modalities of clinical text reports and patient-specific information as inputs, enabling the creation of clinically meaningful ECG signals. Additionally, to address the lack of standardized evaluation in ECG generation, we introduce a comprehensive benchmarking methodology to assess the effectiveness of generative models in this domain. Our model achieve excellent results in tests, proving its superiority in the task of ECG generation. Furthermore, we showcase its potential to mitigate data scarcity while exploring novel applications in cardiology education and medical knowledge discovery, highlighting the broader impact of our work.

Shun Huang, Wenlu Xing, Shijia Geng et al.

Malignant ventricular arrhythmias (VT/VF) following acute myocardial infarction (AMI) are a major cause of in-hospital death, yet early identification remains a clinical challenge. While traditional risk scores have limited performance, end-to-end deep learning models often lack the interpretability needed for clinical trust. This study aimed to develop a hybrid predictive framework that integrates a large-scale electrocardiogram (ECG) foundation model (ECGFounder) with an interpretable XGBoost classifier to improve both accuracy and interpretability. We analyzed 6,634 ECG recordings from AMI patients, among whom 175 experienced in-hospital VT/VF. The ECGFounder model was used to extract 150-dimensional diagnostic probability features , which were then refined through feature selection to train the XGBoost classifier. Model performance was evaluated using AUC and F1-score , and the SHAP method was used for interpretability. The ECGFounder + XGBoost hybrid model achieved an AUC of 0.801 , outperforming KNN (AUC 0.677), RNN (AUC 0.676), and an end-to-end 1D-CNN (AUC 0.720). SHAP analysis revealed that model-identified key features, such as "premature ventricular complexes" (risk predictor) and "normal sinus rhythm" (protective factor), were highly consistent with clinical knowledge. We conclude that this hybrid framework provides a novel paradigm for VT/VF risk prediction by validating the use of foundation model outputs as effective, automated feature engineering for building trustworthy, explainable AI-based clinical decision support systems.

Bin Liu, Qinghao Zhao, Yuxi Zhou et al.

Right heart failure (RHF) is a disease characterized by abnormalities in the structure or function of the right ventricle (RV), which is associated with high morbidity and mortality. Lung disease often causes increased right ventricular load, leading to RHF. Therefore, it is very important to screen out patients with cor pulmonale who develop RHF from people with underlying lung diseases. In this work, we propose a self-supervised representation learning method to early detecting RHF from patients with cor pulmonale, which uses spirogram time series to predict patients with RHF at an early stage. The proposed model is divided into two stages. The first stage is the self-supervised representation learning-based spirogram embedding (SLSE) network training process, where the encoder of the Variational autoencoder (VAE-encoder) learns a robust low-dimensional representation of the spirogram time series from the data-augmented unlabeled data. Second, this low-dimensional representation is fused with demographic information and fed into a CatBoost classifier for the downstream RHF prediction task. Trained and tested on a carefully selected subset of 26,617 individuals from the UK Biobank, our model achieved an AUROC of 0.7501 in detecting RHF, demonstrating strong population-level distinction ability. We further evaluated the model on high-risk clinical subgroups, achieving AUROC values of 0.8194 on a test set of 74 patients with chronic kidney disease (CKD) and 0.8413 on a set of 64 patients with valvular heart disease (VHD). These results highlight the model's potential utility in predicting RHF among clinically elevated-risk populations. In conclusion, this study presents a self-supervised representation learning approach combining spirogram time series and demographic data, demonstrating promising potential for early RHF detection in clinical practice.

Xinyan Guan, Yongfan Lai, Jiarui Jin et al.

Twelve-lead electrocardiograms (ECGs) are the clinical gold standard for cardiac diagnosis, providing comprehensive spatial coverage of the heart necessary to detect conditions such as myocardial infarction (MI). However, their lack of portability limits continuous and large-scale use. Three-lead ECG systems are widely used in wearable devices due to their simplicity and mobility, but they often fail to capture pathologies in unmeasured regions. To address this, we propose WearECG, a Variational Autoencoder (VAE) method that reconstructs twelve-lead ECGs from three leads: II, V1, and V5. Our model includes architectural improvements to better capture temporal and spatial dependencies in ECG signals. We evaluate generation quality using MSE, MAE, and Frechet Inception Distance (FID), and assess clinical validity via a Turing test with expert cardiologists. To further validate diagnostic utility, we fine-tune ECGFounder, a large-scale pretrained ECG model, on a multi-label classification task involving over 40 cardiac conditions, including six different myocardial infarction locations, using both real and generated signals. Experiments on the MIMIC dataset show that our method produces physiologically realistic and diagnostically informative signals, with robust performance in downstream tasks. This work demonstrates the potential of generative modeling for ECG reconstruction and its implications for scalable, low-cost cardiac screening.

Shanwei Zhang, Deyun Zhang, Yirao Tao et al.

Electrocardiogram (ECG) as an important tool for diagnosing cardiovascular diseases such as arrhythmia. Due to the differences in ECG layouts used by different hospitals, the digitized signals exhibit asynchronous lead time and partial blackout loss, which poses a serious challenge to existing models. To address this challenge, the study introduced PatchECG, a framework for adaptive variable block count missing representation learning based on a masking training strategy, which automatically focuses on key patches with collaborative dependencies between leads, thereby achieving key recognition of arrhythmia in ECGs with different layouts. Experiments were conducted on the PTB-XL dataset and 21388 asynchronous ECG images generated using ECG image kit tool, using the 23 Subclasses as labels. The proposed method demonstrated strong robustness under different layouts, with average Area Under the Receiver Operating Characteristic Curve (AUROC) of 0.835 and remained stable (unchanged with layout changes). In external validation based on 400 real ECG images data from Chaoyang Hospital, the AUROC for atrial fibrillation diagnosis reached 0.778; On 12 x 1 layout ECGs, AUROC reaches 0.893. This result is superior to various classic interpolation and baseline methods, and compared to the current optimal large-scale pre-training model ECGFounder, it has improved by 0.111 and 0.19.

Shuhao Mei, Yongchao Long, Shan Cao et al.

Chronic Obstructive Pulmonary Disease (COPD), a major chronic respiratory disease with persistent airflow limitation, is a leading global cause of disability and mortality. Respiratory spirogram time series, routinely collected during pulmonary function tests (PFTs), play a critical role in the early detection of repsiratory diseases and in monitoring lung function over time. However, most current AI models for COPD diagnosis are limited to outputting classification results without providing a rationale for their diagnostic process, while current Large Language Models (LLMs) cannot understand spirograms yet, which severely limits their clinical trust and adoption. To tackle this challenge, we leverage a cohort of 234,028 individuals from the UK Biobank (UKB) to propose SpiroLLM, the first multimodal large language model that can understand spirogram. The model extracts morphological features from respiratory curves via a SpiroEncoder and aligns them with PFT numerical values in a unified latent space using a SpiroProjector, ultimately empowering a large language model to generate a comprehensive diagnostic report. Experimental results confirm that SpiroLLM achieved a diagnostic AUROC of 0.8980 (95% CI: 0.8820-0.9132). In a robustness test with missing core data, it maintained a 100% valid response rate, far surpassing the 13.4% of a text-only model and showcasing the superiority of its multimodal design. This work demonstrates the substantial potential of deeply fusing physiological signals with large language models, establishing a new paradigm for the next generation of interpretable and reliable clinical decision support tools.

Deyun Zhang, Xiang Lan, Shijia Geng et al.

Electrocardiogram (ECG) plays a foundational role in modern cardiovascular care, enabling non-invasive diagnosis of arrhythmias, myocardial ischemia, and conduction disorders. While machine learning has achieved expert-level performance in ECG interpretation, the development of clinically deployable multimodal AI systems remains constrained, primarily due to the lack of publicly available datasets that simultaneously incorporate raw signals, diagnostic images, and interpretation text. Most existing ECG datasets provide only single-modality data or, at most, dual modalities, making it difficult to build models that can understand and integrate diverse ECG information in real-world settings. To address this gap, we introduce MEETI (MIMIC-IV-Ext ECG-Text-Image), the first large-scale ECG dataset that synchronizes raw waveform data, high-resolution plotted images, and detailed textual interpretations generated by large language models. In addition, MEETI includes beat-level quantitative ECG parameters extracted from each lead, offering structured parameters that support fine-grained analysis and model interpretability. Each MEETI record is aligned across four components: (1) the raw ECG waveform, (2) the corresponding plotted image, (3) extracted feature parameters, and (4) detailed interpretation text. This alignment is achieved using consistent, unique identifiers. This unified structure supports transformer-based multimodal learning and supports fine-grained, interpretable reasoning about cardiac health. By bridging the gap between traditional signal analysis, image-based interpretation, and language-driven understanding, MEETI established a robust foundation for the next generation of explainable, multimodal cardiovascular AI. It offers the research community a comprehensive benchmark for developing and evaluating ECG-based AI systems.

Shuhao Mei, Xin Li, Yuxi Zhou et al.

Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung condition characterized by airflow obstruction. Current diagnostic methods primarily rely on identifying prominent features in spirometry (Volume-Flow time series) to detect COPD, but they are not adept at predicting future COPD risk based on subtle data patterns. In this study, we introduce a novel deep learning-based approach, DeepSpiro, aimed at the early prediction of future COPD risk. DeepSpiro consists of four key components: SpiroSmoother for stabilizing the Volume-Flow curve, SpiroEncoder for capturing volume variability-pattern through key patches of varying lengths, SpiroExplainer for integrating heterogeneous data and explaining predictions through volume attention, and SpiroPredictor for predicting the disease risk of undiagnosed high-risk patients based on key patch concavity, with prediction horizons of 1, 2, 3, 4, 5 years, or even longer. Evaluated on the UK Biobank dataset, DeepSpiro achieved an AUC of 0.8328 for COPD detection and demonstrated strong predictive performance for future COPD risk (p-value < 0.001). In summary, DeepSpiro can effectively predicts the long-term progression of the COPD disease.

Wenrui Zhang, Xinxin Di, Guodong Wei et al.

With the development of deep learning-based methods, automated classification of electrocardiograms (ECGs) has recently gained much attention. Although the effectiveness of deep neural networks has been encouraging, the lack of information given by the outputs restricts clinicians' reexamination. If the uncertainty estimation comes along with the classification results, cardiologists can pay more attention to "uncertain" cases. Our study aims to classify ECGs with rejection based on data uncertainty and model uncertainty. We perform experiments on a real-world 12-lead ECG dataset. First, we estimate uncertainties using the Monte Carlo dropout for each classification prediction, based on our Bayesian neural network. Then, we accept predictions with uncertainty under a given threshold and provide "uncertain" cases for clinicians. Furthermore, we perform a simulation experiment using varying thresholds. Finally, with the help of a clinician, we conduct case studies to explain the results of large uncertainties and incorrect predictions with small uncertainties. The results show that correct predictions are more likely to have smaller uncertainties, and the performance on accepted predictions improves as the accepting ratio decreases (i.e. more rejections). Case studies also help explain why rejection can improve the performance. Our study helps neural networks produce more accurate results and provide information on uncertainties to better assist clinicians in the diagnosis process. It can also enable deep-learning-based ECG interpretation in clinical implementation.

Wenrui Zhang, Shijia Geng, Shenda Hong

Learning representations from electrocardiogram (ECG) signals can serve as a fundamental step for different machine learning-based ECG tasks. In order to extract general ECG representations that can be adapted to various downstream tasks, the learning process needs to be based on a general ECG-related task which can be achieved through self-supervised learning (SSL). However, existing SSL approaches either fail to provide satisfactory ECG representations or require too much effort to construct the learning data. In this paper, we propose the T-S reverse detection, a simple yet effective self-supervised approach to learn ECG representations. Inspired by the temporal and spatial characteristics of ECG signals, we flip the original signals horizontally (temporal reverse), vertically (spatial reverse), and both horizontally and vertically (temporal-spatial reverse). Learning is then done by classifying four types of signals including the original one. To verify the effectiveness of the proposed method, we perform a downstream task to detect atrial fibrillation (AF) which is one of the most common ECG tasks. The results show that the ECG representations learned with our method achieve remarkable performance. Furthermore, after exploring the representation feature space and investigating salient ECG locations, we conclude that the temporal reverse is more effective for learning ECG representations than the spatial reverse.

Wenrui Zhang, Shijia Geng, Zhaoji Fu et al.

Ventricular arrhythmias (VA) are the main causes of sudden cardiac death. Developing machine learning methods for detecting VA based on electrocardiograms (ECGs) can help save people's lives. However, developing such machine learning models for ECGs is challenging because of the following: 1) group-level diversity from different subjects and 2) individual-level diversity from different moments of a single subject. In this study, we aim to solve these problems in the pre-training and fine-tuning stages. For the pre-training stage, we propose a novel model agnostic meta-learning (MAML) with curriculum learning (CL) method to solve group-level diversity. MAML is expected to better transfer the knowledge from a large dataset and use only a few recordings to quickly adapt the model to a new person. CL is supposed to further improve MAML by meta-learning from easy to difficult tasks. For the fine-tuning stage, we propose improved pre-fine-tuning to solve individual-level diversity. We conduct experiments using a combination of three publicly available ECG datasets. The results show that our method outperforms the compared methods in terms of all evaluation metrics. Ablation studies show that MAML and CL could help perform more evenly, and pre-fine-tuning could better fit the model to training data.