FOCAL: Fine-Grained Optimal-Transport-Driven Contrastive Alignment of Language and ECGs with Waveform Enhancement

Electrocardiograms (ECGs) are essential non-invasive tools for diagnosing cardiovascular diseases. While recent multimodal ECG-Report contrastive learning methods have shown promise for zero-shot ECG interpretation, they predominantly rely on global representations, failing to capture the fine-grained relationship between localized waveform patches and specific pathological tags. This limitation is further exacerbated by the fact that nearly 55% of standard clinical reports (e.g., in MIMIC-ECG) lack explicit waveform descriptions. In this paper, we propose FOCAL, a novel framework that achieves precise, fine-grained alignment between localized ECG segments and individual report tags via Optimal Transport. Furthermore, because fine-grained alignment at the tag level exacerbates the false negative problem among reports sharing common diagnoses, we introduce a semantic similarity matrix to guide the contrastive objective and correct misalignments. To address the scarcity of detailed waveform text, we introduce a coarse-to-fine enrichment pipeline that leverages Large Language Models (LLMs) to recover missing semantics, utilizing a coarse model verification step to rigorously filter out hallucinations. Extensive experiments across six datasets demonstrate that FOCAL establishes new state-of-the-art performance in zero-shot prediction and linear probing.