arXiv:2603.28532v2 Announce Type: replace-cross Abstract: Low left ventricular ejection fraction (LEF) frequently remains undetected until progression to symptomatic heart failure, underscoring the need for scalable screening strategies. Although artificial intelligence-enabled electrocardiography (AI-ECG) has shown promise, existing approaches rely solely on end-to-end black-box models with limited interpretability or on tabular systems dependent on commercial ECG measurement algorithms with suboptimal performance. We introduced ECG-based Predictor-Driven LEF (ECGPD-LEF), a structured framework that integrates foundation model-derived diagnostic probabilities with interpretable modeling for detecting LEF from ECG. Trained on the benchmark EchoNext dataset comprising 72,475 ECG-echocardiogram pairs and evaluated in predefined independent internal (n=5,442) and external (n=16,017) cohorts, our framework achieved robust discrimination for moderate LEF (internal AUROC 88.4%, F1 64.5%; external AUROC 86.8%, F1 53.6%), consistently outperforming the official end-to-end baseline provided with the benchmark across demographic and clinical subgroups. Interpretability analyses identified high-impact predictors, including normal ECG, incomplete left bundle branch block, and subendocardial injury in anterolateral leads, driving LEF risk estimation. Notably, these predictors independently enabled zero-shot-like inference without task-specific retraining (internal AUROC 75.3-81.0%; external AUROC 71.6-78.6%), indicating that ventricular dysfunction is intrinsically encoded within structured diagnostic probability representations. This framework reconciles predictive performance with mechanistic transparency, supporting scalable enhancement through additional predictors and seamless integration with existing AI-ECG systems.

arXiv:2603.02616v1 Announce Type: cross Abstract: Structural heart disease (SHD) is a prevalent condition with many undiagnosed cases, and early detection is often limited by the high cost and accessibility constraints of echocardiography (ECHO). Recent studies show that artificial intelligence (AI)-based analysis of electrocardiograms (ECGs) can detect SHD, offering a scalable alternative. However, existing methods are fully black-box models, limiting interpretability and clinical adoption. To address these challenges, we propose an interpretable and effective framework that integrates clinically meaningful ECG foundation-model predictors within a generalized additive model, enabling transparent risk attribution while maintaining strong predictive performance. Using the EchoNext benchmark of over 80,000 ECG-ECHO pairs, the method demonstrates relative improvements of +0.98% in AUROC, +1.01% in AUPRC, and +1.41% in F1 score over the latest state-of-the-art deep-learning baseline, while achieving slightly better performance even with only 30% of the training data. Subgroup analyses confirm robust performance across heterogeneous populations, and the estimated entry-wise functions provide interpretable insights into the relationships between risks of traditional ECG diagnoses and SHD. This work illustrates a complementary paradigm between classical statistical modeling and modern AI, offering a pathway to interpretable, high-performing, and clinically actionable ECG-based SHD screening.