Foundation models for generalizable electrocardiogram interpretation: comparison of supervised and self-supervised electrocardiogram foundation models

Abstract Background The 12-lead electrocardiogram (ECG) remains a cornerstone of cardiac diagnostics, yet existing artificial intelligence (AI) solutions for automated interpretation often lack generalizability, remain closed-source, and are primarily trained using supervised learning, limiting their adaptability across diverse clinical settings. To address these challenges, we developed and compared two open-source foundational ECG models: DeepECG-SSL, a self-supervised learning model, and DeepECG-SL, a supervised learning model. Methods Both models were trained on over 1 million ECGs using a standardized preprocessing pipeline and automated free-text extraction from ECG reports to predict 77 cardiac conditions. DeepECG-SSL was pretrained using self-supervised contrastive learning and masked lead modeling. The models were evaluated on six multilingual private healthcare systems and four public datasets for ECG interpretation across 77 diagnostic categories. Fairness analyses assessed disparities in performance across age and sex groups, while also investigating fairness and resource utilization. Results DeepECG-SSL achieved AUROCs of 0.990 (95%CI 0.990, 0.990) on internal dataset, 0.981 (95%CI 0.981, 0.981) on external public datasets, and 0.983 (95%CI 0.983, 0.983) on external private datasets, while DeepECG-SL demonstrated AUROCs of 0.992 (95%CI 0.992, 0.992), 0.980 (95%CI 0.980, 0.980) and 0.983 (95%CI 0.983, 0.983) respectively. Fairness analyses revealed minimal disparities (true positive rate & false positive rate difference<0.010) across age and sex groups. Digital biomarker prediction (Long QT syndrome (LQTS) classification, 5-year atrial fibrillation prediction and left ventricular ejection fraction (LVEF) classification) with limited labeled data, DeepECG-SSL outperformed DeepECG-SL in predicting 5-year atrial fibrillation risk (N=132,050; AUROC 0.742 vs. 0.720; Δ=0.022; P<0.001), identifying reduced LVEF ≤40% (N=25,252; 0.928 vs. 0.900; Δ=0.028; P<0.001), and classifying LQTS syndrome subtypes (N=127; 0.931 vs. 0.853; Δ=0.078; P=0.026). Conclusion By releasing model weights, preprocessing tools, and validation code, we aim to support robust, data-efficient AI diagnostics across diverse clinical environments. This study establishes self-supervised learning as a promising paradigm for ECG analysis, particularly in settings with limited annotated data, enhancing accessibility, generalizability, and fairness in AI-driven cardiac diagnostics. Key Question Can self-supervised (SSL) learning yield ECG-based AI foundational models with enhanced performance, fairness, privacy, and generalizability compared to traditional supervised learning (SL) approaches? Key Finding Our evaluation of DeepECG-SL and DeepECG-SSL across seven external health center datasets and four international publicly accessible datasets demonstrated that while both models achieve comparable diagnostic accuracy for ECG interpretation, SSL outperforms SL on novel tasks with smaller datasets. Take-home Message We validated DeepECG-SL and DeepECG-SSL across public and private datasets and demonstrated that SSL model had a superior generalizability by addressing fairness, privacy, and efficiency, and open sourcing our models, we advance ethical, adaptable AI for equitable, real-world ECG diagnostics. Abstract Figure Graphical abstract: DeepECG-SL and DeepECG-SSL, two open-source AI models for 12-lead ECG interpretation, were trained on over 1 million ECGs. DeepECG-SSL, utilizing self-supervised contrastive learning and masked lead modeling, outperformed DeepECG-SL in utilizing digital biomarkers to predict atrial fibrillation risk, reduced LVEF, and long QT syndrome subtypes, while both models achieved high diagnostic accuracy with minimal fairness disparities across age and sex. Validated on ten external datasets, our work provides a robust, reproducible framework for equitable, efficient ECG-based cardiac diagnostics.

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