By: Vijay R ECG Analysis System

1. Abstract

Electrocardiograph (ECG) is a transthoracic interpretation of the electrical activity of

the heart over time captured and externally recorded by skin electrodes.

The ECG works mostly by detecting and amplifying the tiny electrical changes on the
skin that are caused when the heart muscle "depolarizes" during each heart beat. At rest,
each heart muscle cell has a charge across its outer wall, or cell membrane. Reducing this
charge towards zero is called de-polarization, which activates the mechanisms in the cell
that cause it to contract. During each heartbeat a healthy heart will have an orderly
progression of a wave of depolarization that is triggered by the cells in the sanatoria node,
spreads out through the atrium, passes through "intrinsic conduction pathways" and then
spreads all over the ventricles. This is detected as tiny rises and falls in the voltage
between two electrodes placed either side of the heart which is displayed as a wavy line
either on a screen or on paper. This display indicates the overall rhythm of the heart and
weaknesses in different parts of the heart muscle.

Usually more than 2 electrodes are used and they can be combined into a number of pairs
(For example: Left arm (LA), right arm (RA) and left leg (LL) electrodes form the pairs:
LA+RA, LA+LL, RA+LL). The output from each pair is known as a lead. Each lead is
said to look at the heart from a different angle. Different types of ECGs can be referred to
by the number of leads that are recorded, for example 3-lead, 5-lead or 12-lead ECGs
(sometimes simply "a 12-lead"). A 12-lead ECG is one in which 12 different electrical
signals are recorded at approximately the same time and will often be used as a one-off
recording of an ECG, typically printed out as a paper copy. 3- and 5-lead ECGs tend to
be monitored continuously and viewed only on the screen of an appropriate monitoring
device, for example during an operation or whilst being transported in an ambulance.
There may, or may not be any permanent record of a 3- or 5-lead ECG depending on the
equipment used.

It is the best way to measure and diagnose abnormal rhythms of the heart, particularly
abnormal rhythms caused by damage to the conductive tissue that carries electrical
signals, or abnormal rhythms caused by electrolyte imbalances. In a myocardial
infarction (MI), the ECG can identify if the heart muscle has been damaged in specific
areas, though not all areas of the heart are covered. The ECG cannot reliably measure the
pumping ability of the heart, for which ultrasound-based (echocardiography) or nuclear
medicine tests are used. It is possible to be in cardiac arrest with a normal ECG signal (a
condition known as pulse less electrical activity).

2. HISTORY
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By: Vijay R ECG Analysis System

An initial breakthrough came when Willem Einthoven, working in Leiden, Netherlands,

used the string galvanometer that he invented in 1903. This device was much more
sensitive than both the capillary electrometer that Waller used and the string
galvanometer that had been invented separately in 1897 by the French engineer Clément
Ader. Rather than using today's self-adhesive electrodes Einthoven's subjects would
immerse each of their limbs into containers of salt solutions from which the ECG was
recorded.

Einthoven assigned the letters P, Q, R, S and T to the various deflections, and described
the electrocardiographic features of a number of cardiovascular disorders. In 1924, he
was awarded the Nobel Prize in Medicine for his discovery.

Though the basic principles of that era are still in use today, there have been many
advances in electrocardiography over the years. The instrumentation, for example, has
evolved from a cumbersome laboratory apparatus to compact electronic systems that
often include computerized interpretation of the electrocardiogram.

ECG interpretation techniques were initially developed and used on mainframe

computers in the early 1960s (Pordy et al., 1968). In those days, mainframe computers
centrally located in computing centers performed the ECG analysis and interpretation.
The ECGs were transmitted to the computer from remote hospital sites using a specially
designed ECG acquisition cart that could be rolled to the patient’s bedside. The cart had
three ECG amplifiers, so three leads were acquired simultaneously and transmitted over
the voice-grade telephone network using a three-channel analog FM modem. The
interpretation program running in the mainframe computer consisted of several hundred
thousand lines of FORTRAN code. As technology evolved, minicomputers located
within hospitals took over the role of the remote mainframes. The ECG acquisition carts
began to include embedded microprocessors in order to facilitate ECG capture. Also,
since the interpretation algorithms had increased failure rates if the ECG was noisy, the
microprocessors increased the signal-to-noise ratio by performing digital signal
preprocessing algorithms to remove baseline drift and to attenuate power line
interference. Ultimately the ECG interpretation programs were incorporated within the
bedside carts themselves, so that the complete process of acquisition, processing, and
interpretation could be done at the patient’s bedside without transmitting any data to a
remote computer. This technology has now evolved into stand-alone microprocessor-
based interpretive ECG machines that can be battery powered and small enough to fit in a
briefcase. The early ECG carts had three built-in ECG amplifiers and transmitted 2.5-
second epochs of three simultaneous channels. In order to acquire all 12 leads, they
sequenced through four groups of three leads each, requiring 10 seconds to send a
complete record. Thus, the four acquired three-lead sets represented four different time
segments of the patient’s cardiac activity. Since a 2.5-second interval only includes two

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or three heartbeats, the early algorithms had difficulty in deducing abnormalities called
arrhythmias in which several heartbeats may be involved in a rhythm disturbance. In
order to improve arrhythmia analysis, three additional leads, typically the VCG leads,
were recorded for a longer period of six seconds and added to the acquired data set
(Bonner and Schwetman, 1968).

The modern microprocessor-based interpretive machines include eight ECG

amplifiers so that they can simultaneously sample and store eight leads—I, II, and V1–
V6. They then synthesize the four redundant leads—III, aVR, aVL, and aVF .These
machines include enough memory to store all the leads for a 10-second interval at a
clinical sampling rate of 500 sps.

3) Interpretation of the 12-lead ECG

Feature Extraction:

ECG interpretation starts with feature extraction, which has two parts as shown in. The
goals of this process are (1) waveform recognition to identify the waves in the ECG
including the P and T waves and the QRS complex, and (2) measurement to quantify a

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By: Vijay R ECG Analysis System

set of amplitudes and time durations that is to be used to drive the interpretation process.
Since the computer cannot analyze the ECG waveform image directly like the human
eye-brain system, we must provide a relevant set of numbers on which it can operate.

The first step in waveform recognition is to identify all the beats using a QRS detection
algorithm. Second, the similar beats in each channel are time-aligned and an average (or
median) beat is produced for each of the 12 leads. These 12 average beats are analyzed to
identify additional waves and other features of the ECG, and a set of measurements is
then made and assembled into a matrix. These measurements are analyzed by subsequent
processes.

The 12-lead ECG of a normal male patient

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By: Vijay R ECG Analysis System

There are two basic approaches for computerized interpretation of the ECG.
The one used in modern commercial instrumentation is based on decision logic. A
computer program mimics the human expert’s decision process using a rule-based expert
system. The second approach views ECG interpretation as a pattern classification
problem and applies a multivariate statistical pattern recognition method to solve it.

The decision logic:

The decision logic approach is based on a set of rules that operate on the measurement
matrix derived from the ECG. The rules are assembled in a computer program as a large
set of logical IF-THEN statements. For example, a typical decision rule may have the
following format:
Rule 0021: IF
(1) QRS ³ .11 sec. on any two limb leads AND
(2) Sd. ³ .04 sec. on lead I or aVL AND
(3) Terminal R present lead Vl
THEN
(a) QRS .11 seconds; AND
(b) Terminal QRS rightward and anterior; AND
(c) Incomplete right bundle branch block
One advantage of the decision logic approach is that its results and the decision process
can easily be followed by a human expert. However, since its decision rules are elicited
indirectly from human experts rather than from the data, it is likely that such a system
will never be improved enough to outperform human experts. Unlike human experts, the
rule-based classifier is unable to make use of the waveforms directly. Thus, its capability
is further limited to looking at numbers that are extracted from the waveforms that may
include some measurement error. Also, with such an approach, it is very difficult to make

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By: Vijay R ECG Analysis System

minor adjustments to one or few rules so that it can be customized to a particular group of
patients.

Figure shows the final summary provided to the clinician by an interpretive

ECG machine for the ECG

3) Empirical Mode Decomposition

A new non-linear technique, called Empirical Mode Decomposition method, has recently
been developed by N.E.Huang et al for adaptively representing non-stationary signals as
sums of zero mean AM-FM components. EMD is an adaptive, high efficient
decomposition with which any complicated signal can be decomposed into a finite
number of Intrinsic Mode functions (IMFs). The IMFs represent the oscillatory modes
embedded in the signal, hence the name Intrinsic Mode Function.

The starting point of EMD is to consider oscillations in signals at a very local level. It is
applicable to non-linear and non-stationary signal such as ECG signal.
An Intrinsic Mode function is a function that satisfies two conditions [6]:
(1) The number of extreme and the number of zero crossings must differ by at most 1.

(2) At any point the mean value of the envelope defined by maxima and the envelope
defined by minima must be zero.

The whole procedure can be described by the following algorithm.

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By: Vijay R ECG Analysis System

• The ECG signal is first decomposed into IMFs. The sum of these IMFs
should represent the signal well. The IMFs are obtained using the sifting process
described in the earlier section.
• The first four IMFs are filtered to remove noise. We use a low pass filter as
the noise comprises the higher frequency components. The filter used by us in
programming is the low pass Butterworth filter. We use a Butterworth filter
because of its inherent characteristics of having a flat frequency response.
• The 1st IMF is now eliminated. We reconstruct the enhanced signal by
eliminating the 1st IMF and adding up the rest IMFs.
The enhancement algorithm was then used and the SNRs of the enhanced signals were
calculated to find the efficiency of the proposed

Although this method is very crude it comes with some advantages.

The unwanted effects of large peaked T and P waves are minimized. Moreover it has
been shown to perform extremely well in the presence of noise.

FUTURE WORK

Empirical Mode Decomposition and Wavelet Transform are both very recent
techniques. Hence a lot of research needs to be done on the properties so that we can
come up with still simpler methods for ECG signal Analysis.

Feature extraction is yet another field in ECG signal Analysis untouched by us.
But it is very important for classification of Arrthymia. Hence our future work will be
dedicated to feature extraction and classification.

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By: Vijay R ECG Analysis System

The process of enhancement can be modified using more evolved techniques.

Research needs to be done for finding more efficient methods for signal enhancement.

4) TYPES OF ECG
(Based on number of leads)

1 lead, 3 lead, 5lead, 6 leads, 8leads, 12 leads.

The best type out of the above is 12 lead ECG as it is the most reliable as it gives the
most accurate results about.

The Leads in a 12 lead ECG are RA, LA, RL, LL, V1, V2, V3, V4, V5, V6 and the 2 limb
leads L1 and L2.

5) ST-SEGMENT ANALYZER

The ST-segment represents the period of the ECG just after depolarization, the QRS
complex, and just before re-polarization, the T wave. Changes in the ST-segment of the
ECG may indicate that there is a deficiency in the blood supply to the heart muscle. Thus,
it is important to be able to make measurements of the ST-segment. This section
describes a microprocessor-based device for analyzing the ST segment.

ECG with several features marked. The analysis begins by detecting the QRS waveform.
Any efficient technique can be implemented to do this. The R wave peak is then
established by searching the interval corresponding to 60 ms before and after the QRS
detection mark, for a point of maximal value. The Q wave is the first inflection point

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By: Vijay R ECG Analysis System

prior to the R wave. This inflection point is recognized by a change in the sign of slope,
zero slopes, or a significant change in slope. The three-point difference derivative method
is used to calculate the slope.

If the ECG signal is noisy, a low-pass digital filter is applied to smooth the data before
calculating the slope. The isoelectric line of the ECG must be located and measured. This
is done by searching between the P and Q waves for a 30-ms interval of near-zero slopes.
In order to determine the QRS duration, the S point is located as the first inflection point
after the R wave using the same strategy as for the Q wave. Measurements of the QRS
duration, R-peak magnitude relative to the isoelectric line, and the RR interval are then
obtained. The J point is the first inflection point after the S point, or may be the S point
itself in certain ECG waveforms. The onset of the T wave, defined as the T point, is

found by first locating the T-wave peak which is the maximal absolute value, relative to
the isoelectric line, between J + 80 ms and R + 400 ms. The onset of the T wave, the T
point, is then found by looking for a 35-ms period on the R side of the T wave, which has
values within one sample unit of each other. The T point is among the most difficult
features to identify. If this point is not detected, it is assumed to be J + 120 ms.
Having identified various ECG features, ST-segment measurements are made using a
windowed search method. Two boundaries, the J + 20 ms and the T point, define the
window limits. The point of maximal depression or elevation in the window is then
identified. ST-segment levels can be expressed as the absolute change relative to the
isoelectric line.

In addition to the ST-segment level, several other parameters are calculated. The ST
slope is defined as the amplitude difference between the ST-segment point and the T
point divided by the corresponding time interval. The ST area is calculated by summing
all sample values between the J and T points after subtracting the isoelectric- line value

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By: Vijay R ECG Analysis System

from each point. An ST index is calculated as the sum of the ST segment level and one-
tenth of the ST slope.

6) QRS Complex Detection Rules

The QRS complex is the name for some of the deflections seen on a typical
electrocardiogram (ECG). It is usually the central and most visually obvious part of the
tracing. The QRS complex corresponds to the depolarization (depolarization is a change
in a cell's membrane potential, making it more positive, or less negative) of the right and
left ventricles. Classically the ECG tracing has 5 deflections, arbitrarily named P to T
waves. The Q, R and S wave occur in rapid succession, do not all appear in all leads and
reflect a single event so are thus normally considered as a whole complex. A Q wave is
any downward deflection after the P-wave. An R-wave is an upward deflection and the S
wave is any downward deflection after the R-wave.

Software QRS detectors are an integral part of the modern computerized ECG monitoring
system, the most use is in the ICU where the algorithm must run in real time. In
arrhythmia monitoring system significant false positive and negative rates can cause
faulty QRS detection.

QRS detectors are divided into 2 components

The Processor: Produces set of linear and non linear filtering of ECG signals.
The Decision Logic: Used in determination of detection threshold. These are
assembled in ad hoc fashion.

Processor

The processor does linear and non linear digital filtering and peak detection

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By: Vijay R ECG Analysis System

Filter stages

The low pass filter along with high pass filter forms the band pass filter that can be
implemented with integer arithmetic for real time operations. This is followed by
differential, squaring and averaging.

The Low pass filter is one of the one of the class filters implemented using differential
equation
y(nT)=2y(nT-T)-y(nT-2T)+x(nT)-2x(nT-6T)+x(nT-12T)
Where T is an arbitrary value.

The High pass filter are implemented using the differential equation
y(nT)=2y(nT-T)-x(nT)/32+x(nT-16T)-x(nT-17T)+x(nT-32T)/32

The differential is implemented as

y(nT)=[2x(nT)+x(nt-T)-x(nT-3T)-2x(nT-4T)]/8

Peak Detection

The peak level estimation is an important performance factor in QRS detection algorithm.
The mean peak detector detects the peak as local mean of specified number of past peaks.
The median peak detector uses median peak values.
The first order iterative estimator has the general form
Estimate (n) = (1-A)*Estimate (n-1) +A*peak (n)
Where A is a positive coefficient less than 1
The prediction of the peak always will not be ideal and hence has errors.
The 3 estimators were applied to the peaks derived from time averaged signal plotted.

The median predictor has lower error than mean and iterative predictors.
The error is less when previous 7 or 8 values are used for prediction.

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Peak Estimator Performance

The ultimate performance measure is its effect on QRS detection.

One estimate may have low peak prediction error and some may have better mean square
error and inconsistent prediction. Hence a consistent predictor is used to have an output
that has less positive and negative detection if proper relative threshold is used.

Decision threshold= B*peak level estimate

Where 0<B<1

Any peak larger than the detection threshold will be classified as QRS complex and are
used to update the decision threshold. The noise peaks are ignored.

The mean and median were used with varying detection threshold and iterative thresholds
and hence obtained the result from 0.01 to 0.99 in 100 trials and obtained the result:

Decision threshold

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By: Vijay R ECG Analysis System

Decision threshold is calculated using

1] Noise peak level.
2] Threshold Coefficient.
3] QRS peak level
DT=NPL+TC*(NPL-QRSPL)

Here 3 to 12 peak levels were used and coefficients to be between 0.01 to 0.9. Thus a
QRS detector with 10 data point median and threshold of 0.133 gave a minimal number
of 1974 false detections.

Here we have the statistics of the influence of QRS detectors (factors added to QRS
detectors).
a) Iterative peak estimator.
b) Mean Peak level estimator.
c) Median peak level estimator.
d) Detection threshold that includes noise peak estimate.
e) 200ms Refractory banking.
f) Search back method.

7) CONCLUSION

Thus using all above logic and enhancement methods an ECG is assessed and hence the
decision is made. Thus the decision that the person is normal is given . The ECG of a
normal person is as shown:

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The ECG of a person Acute inferior myocardial infarction (Heart Attack) :

The change is significant.

REFERENCES

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Yan Lu, Jingyu Yan, and Yeung Yam, “Model Based ECG denoising using
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Bioinformatics and Biomedicine, pp. 191-196, 2009.

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