Echocardiography is the cornerstone of cardiovascular diagnostics, yet its global utility is constrained by a critical shortage of experienced interpreters. Current artificial intelligence (AI) solutions remain limited, typically operating as opaque "black boxes" or focusing on narrow tasks that fail to capture the holistic, guideline-driven reasoning of a clinician. Here we introduce EchoChat, a generative multimodal vision-language model that performs comprehensive echocardiographic analysis to support clinician interpretation. By emulating the cognitive workflow of a cardiologist, EchoChat integrates vast medical knowledge with a chain-of-thought reasoning mechanism to explicitly ground its conclusions in visual evidence. Trained on echocardiography-instruction pairs from 46,358 examinations, our model establishes a new state-of-the-art across diverse cohorts from six international medical centers. It supports the broadest diagnostic scope of 33 cardiac conditions and findings, including 15 newly added conditions for which it achieves an average F1 of 73.7% across available external evaluations. It surpasses existing best-performing foundation models in cardiac condition recognition (improving average recall by 13.54% on shared tasks) and quantification (average R2 score increase of 0.275 on shared tasks). Furthermore, in a source-blinded echocardiographer reader study, echocardiography reports co-generated with EchoChat were rated higher in diagnostic accuracy and completeness by two senior echocardiographers, and improved diagnostic performance from 72.78% to 82.75% in terms of F1 score over routine-reader only reports. These results demonstrate that integrating clinical reasoning into multimodal AI can democratize specialist expertise and transform the standard of cardiovascular care.

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