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ECG-LLM: Foundation Model for ECG-Based Cardiac Reasoning

MCML Authors

Abstract

Electrocardiography (ECG) is an inexpensive, standard-of-care test for cardiac symptoms, but front-line triage often lacks immediate access to definitive imaging such as echocardiography (ECHO) or cardiac magnetic resonance (CMR). Furthermore, most existing ECG-AI systems are limited to fixed diagnostic labels or automated reports, constraining their use for patient-specific clinical reasoning. To address this gap, we introduce ECG-LLM, an ECG-conditioned large language model trained across four cohorts comprising 679,112 ECG studies from 186,409 patients. Using a novel multimodal-to-language supervision strategy, ECG-LLM is trained on clinically structured question-answer pairs derived from ECG signals, clinical context, CMR, and ECHO. This unified approach enables the model to answer diverse cardiovascular questions from a 12-lead ECG alone, spanning both conventional interpretation and phenotypes not directly visible on standard ECGs. ECG-LLM successfully recovers conventional ECG measurements, such as heart rate, and strongly predicts complex CMR-derived phenotypes, including ventricular and atrial volumes and ventricular function. Crucially, it detects vital echocardiographic phenotypes, including increased LV wall thickness, aortic stenosis, and right-ventricular systolic dysfunction. On standard ECG understanding tasks, ECG-LLM matches or exceeds existing baselines for diagnostic report generation and the ECG-QA benchmark. By moving beyond fixed-label prediction, this multimodal framework provides clinically valuable, question-driven cardiovascular reasoning to support general practitioner and front-line triage decisions when specialist review is delayed.

misc SJK+26a

Preprint

Jul. 2026

Authors

A. Selivanov • F. Jungmann • J. A. Kehrer • K.-L. Laugwitz • E. Martens • D. Rückert

Links

DOI URL

Research Area

 C1 | Medicine

BibTeXKey: SJK+26a

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