Wearable-Echo-FM: An ECG-echo foundation model for single lead electrocardiography

Artificial intelligence (AI) models can now detect patterns of structural heart diseases (SHDs) from electrocardiograms (ECGs), though scaling them requires the broader use of single–lead ECGs that are now ubiquitous in wearable and portable devices. However, model development for these devices is limited by a lack of diagnostic labels for SHDs for wearable ECGs. Here, we present Wearable–Echo–FM, a foundation model that encodes single-lead ECGs with information from echocardiographic text reports. Using 274,057 single-lead ECG-echo pairs from 77,378 adults (2015–2019), we contrastively pre–trained convolutional neural network (CNN) and RoBERTa encoders. The ECG encoder was fine–tuned on a distinct progressively larger ECG set (250 to 250,260 ECGs) to detect different cardiac disorders (i) left–ventricular systolic dysfunction (LVSD), (ii) diastolic dysfunction, and (iii) a composite SHD. This was compared with a randomly initialized CNN, with both approaches evaluated in an independent held-out test set. With the full training set, Wearable–Echo–FM matched the baseline CNN (AUROC 0.894 vs 0.884 for LVSD; 0.849 vs 0.843 diastolic dysfunction; 0.887 vs 0.869 composite). With only 0.5% (~1000 ECGs) of data, it markedly outperformed baseline (0.855 vs 0.548; 0.819 vs 0.582; 0.863 vs 0.496, respectively). Contrastive pre–training of single-lead ECGs on echocardiographic text reduces label requirements for SHD screening on wearable and portable devices.