Real-time electrocardiogram (ECG) monitoring and diagnosis through Internet of Things (IoT) are crucial for addressing the severity and timely treatment of cardiovascular diseases, enabling timely intervention and preventing life-threatening complications. However, current ECG monitoring research predominantly focuses on individual aspects such as signal compression, diagnostic analysis, or secure transmission, lacking joint optimization of various modules in IoT scenarios. To address this gap, this work proposes a novel framework based on superimposed semantic communication for real-time ECG monitoring in IoT. The framework comprises three hierarchical levels: the edge level for data collection and processing, the relay level for signal compression and coding, and the cloud level for data analysis and reconstruction. The proposed framework offers several unique advantages. By employing semantic encoding guided by ECG classification tasks, it selectively extracts crucial features within and between signals, improving compression ratio and adaptability to channel noise. The superimposed semantic encoding achieves content encryption without requiring any additional operations. Moreover, the framework utilizes lightweight anomaly detection neural networks, reducing edge device power consumption and conserving communication resources. Simulation and real experimental results demonstrate that the proposed method achieves real-time encoding and transmission of ECG signals with a compression ratio of 0.019 on the MIT-BIH dataset. Furthermore, it attains a heartbeat classification accuracy of 0.988 and a reconstruction error of 0.061.