ECG-InterpBench: Benchmarking the Interpretability of ECG Foundation Models with Matched-Scale Sparse Autoencoders

Existing benchmarks for electrocardiogram foundation models primarily evaluate downstream predictive performance, providing limited insight into whether their internal representations can be faithfully decomposed, clinically interpreted, or reproduced across independent analyses. We introduce ECG-InterpBench, a benchmark designed to systematically evaluate the interpretability of ECG foundation-model representations. ECG-InterpBench uses sparse autoencoders as standardized measurement instruments and matches their capacity across models to enable controlled comparisons. We evaluate six frozen ECG foundation models across five standardized encoder depths, five matched dictionary widths, and three random seeds, producing a 450-cell interpretability atlas comprising 75 exactly matched six-model comparison blocks. The benchmark evaluates complementary dimensions of representation interpretability, including sparse reconstruction fidelity, single-feature accessibility and coverage of 49 clinically meaningful ECG measurements, and cross-seed feature reproducibility. The evaluation further quantifies patient-sampling uncertainty, depth- and seed-dependent variation, and sensitivity to the sparsity parameterization. The benchmark reveals that ECG foundation models exhibit distinct interpretability profiles. A matched replication on MIMIC-IV-ECG confirms that reconstruction fidelity and clinical accessibility identify different leading models. The benchmark is accompanied by executable evaluation code, standardized manifests, cell-level metrics, and reproducibility audits. ECG-InterpBench complements performance-centered ECG benchmarks by providing a capacity-controlled and reproducible framework for comparing ECG foundation models across distinct dimensions of representation interpretability.

CADENCE: A Cardiac Atom Dictionary for Interpretable Neural Concept Extraction from ECG Foundation Models

Foundation models for 12-lead electrocardiograms (ECGs) transfer well across clinical tasks, but the physiological knowledge encoded in their representations remains opaque. We present CADENCE, a framework that decomposes an ECG foundation model into a human-interpretable, queryable dictionary of physiological concepts. Using a BatchTopK sparse autoencoder, CADENCE factorizes Layer-6 embeddings from more than nine million ECG tokens into 8,192 sparse cardiac atoms. These atoms align better than individual dense embedding dimensions with clinical phenotypes and waveform morphology, recovering arrhythmias, conduction abnormalities, infarction and repolarization patterns, chamber and axis findings, and lead- and beat-phase-specific waveform primitives. At Layer 6, the best atoms achieve mean AUROCs of 0.88 for clinical phenotypes and 0.90 for morphology, versus 0.78 and 0.83 for the best dense dimensions. Sparse atom probes match or outperform dense probes for phenotype, morphology, and age prediction while attributing each prediction to a small set of interpretable atoms; phenotype AUROC improves from 0.93 to 0.95. Atom-space geometry recovers physiologically coherent relationships, and targeted atom ablation selectively changes frozen downstream outputs. An automated LLM pipeline generates and quantitatively validates atom descriptions by predicting held-out activations. On independent external ECG datasets, CADENCE recovers overlapping concepts and maintains consistent phenotype-prediction performance. CADENCE provides a scalable framework for discovering and auditing the physiological knowledge encoded by ECG foundation models.