Differentiating Ischemic From Nonischemic T-Wave Inversion Using a Multimodal Vision-Language Model With Reinforcement Learning (ECG-R1): Development and Validation Study

<sec> <title>BACKGROUND</title> The differentiation of ischemic from non-ischemic T-wave inversion (TWI) on electrocardiograms (ECGs) is a critical diagnostic challenge in cardiology. The non-specific nature of TWI leads to high false-positive rates, resulting in unnecessary, costly, and risky invasive procedures for patients. Existing deep learning models are often limited by being single-modality "black boxes". </sec> <sec> <title>OBJECTIVE</title> The objective of this study is to develop a novel diagnostic framework designed to address the critical clinical challenge of accurately differentiating ischemic from non-ischemic TWI. By utilizing a multi-modal Vision-Language Model trained with a Reinforcement Learning (RL) paradigm, this study aims to improve diagnostic accuracy and provide interpretable reasoning. </sec> <sec> <title>METHODS</title> We develop ECG-R1, a multi-modal framework using the Qwen2-VL-2B Vision-Language Model to analyze both ECG waveform images and associated clinical text. Instead of SFT, the model is trained using a RL paradigm with the Group Relative Policy Optimization (GRPO) algorithm. The model is trained to generate a structured output containing an explicit reasoning trace and a final "Yes" or "No" answer. A two-component, rule-based reward function is designed to assess both format adherence and diagnostic accuracy. Performance is compared against strong Supervised Fine-Tuning (SFT) baselines. </sec> <sec> <title>RESULTS</title> On a multi-modal dataset of 12,917 cases with TWI, our GRPO model achieves an average accuracy of 74.07%, demonstrating strong generalization with 72.93% accuracy in cross-hospital validation. This result is an improvement of ~24 % over the ~50% diagnostic accuracy of clinicians and 8.2% higher than the best SFT baseline, using ~71% fewer parameters. </sec> <sec> <title>CONCLUSIONS</title> The RL-based ECG-R1 framework successfully differentiates ischemic from non-ischemic TWI and demonstrates significantly better generalization than standard SFT methods. By enhancing diagnostic accuracy and providing interpretable reasoning, this approach offers a more robust and trustworthy tool to support clinical decision-making in cardiology. </sec>

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