RESEARCH ARTICLE

Copyright 2011 American Scientic Publishers All rights reserved Printed in the United States of America

Journal of Medical Imaging and Health Informatics

Vol. 1, 225230, 2011

Real-Time Detection of Myocardial Infarction by Evaluation of ST-Segment in Digital ECG

Sadeer G. Al-Kindi1 and Reza Tafreshi2
2

Weill Cornell Medical College, P.O. Box 24144, Doha, Qatar Department of Mechanical Engineering, Texas A&M University, P.O Box 23874, Doha, Qatar

Myocardial infarction (MI) is one of the Delivered most common sudden-onset heart diseases. Early diagnosis and manby Ingenta to: agement of heart ischemia result in good prognosis. Early changes in the heart muscle activity after ischemia Guest User reect in ST segment elevation on electrocardiogram (ECG) recordings. With the development of signal processIP : 39.48.158.232 ing techniques and the portable devices, there is a need to develop a real-time algorithm that accurately detects Sat, Jul 2012 09:21:16 MI non-invasively. In this paper, we propose 07 a computer algorithm that employs digital analysis scheme towards the real-time detection of MI. The proposed algorithm extract features based on clinical diagnosis conditions allowing the continuous analysis of ST segment and simultaneous detection of abnormal heart activity resulting from MI. Using an online ECG library of patient data, the signals were ltered for high frequency noise, baseline drift then features of interest (Q, R, S waves and J points) were extracted. These were used to measure the ST segment elevation and depression as an important indicator of MI dened in clinical guideline for MI diagnosis. The developed algorithm was capable of detecting MI with 85% sensitivity and 100% specicity in a test set of 40 ECG recordings.

Keywords: Automatic Detection, Myocardial Infarction, Digital Analysis, ECG.

1. INTRODUCTION
Heart disease is the leading cause of mortality and morbidity in the United States1 and myocardial infarction (MI) constitutes more than 10% of the heart disease cases.2 Early diagnosis of myocardial infarction is essential for the management and treatment initiation. MI occurs when there is an ischemic event due to the occlusion of one of the three arteries supplying the heart muscle. This occlusion leads to the death of the part of the heart muscle supplied by the branches distal to the occlusion. This tissue death produces changes in the electrocardiogram (ECG) signal early in the stage of progression and change in cardiac serum markers later. Thus, one of the criteria for detecting STelevation MI (STEMI) within the early hours of the event is the ST segment analysis in ECG recording.3 ST elevation has been associated with up to 99.7% accuracy in detecting acute MI in admitted patients.4 Continuous monitoring of ST segment has proven effective in patients with chest pain and non-diagnostic ECG within the rst 6 hours.5 ST segment monitoring is also important in other aspects of clinical trials,6 research projects, and for the assessment of coronary reperfusion after occlusion.7 However,

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visual analysis of long-term ECG recordings is time- and cost-ineffective. Figure 1 shows the typical representation of a waveform from lead I ECG recording. Features of interest to this project are labeled: Q, R, S, Reference Point (REF), and J point. The reference point (REF) represents the PQ segment. ST segment is dened as the segment between the end of S wave and the starting of T wave. J point is dened as the end point of S wave. The representative point of ST segment used in clinical decisions is 80 ms after the J point. Telemetric ECG devices such as Holter monitors have been in the clinical use since 1960s. Holter provides longer duration recordings of the cardiac activity. However, it is limited by low resolution and offer ofine and little, if any, real-time analysis which might not help in detecting the onset of acute cardiac ischemia.8 A number of computerized algorithms have been suggested in the literature. Maglaveras et al. implemented a supervised neural network-based algorithm for automated detection of ischemic episodes resulting from ST segment elevation or depression (sensitivity of 88.62%).9 Asfar et al. also investigated ST detection and analysis through a proposed system employing lead-dependent Karhunen-Love transform and neural classier.10 Smrdel and Jager proposed an algorithm for ST-segment analysis in 24 h ambulatory ECG recordings doi:10.1166/jmihi.2011.1032 225

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Forty 12-lead ECG recordings (ranging in length 2050 s) were used for this study; twenty of which were from healthy controls and twenty were from patients with acute myocardial infarction. Clinical diagnoses were provided for each recording and were used to assess our algorithm in diagnosing MI. 2.2. Baseline Drift Removal Baseline Drift is a common problem in ECG recordings. Baseline drift forms from low frequency sources (e.g., respiration, movement). We estimated the baseline drift by applying a 3rdorder Butterworth low-pass digital lter with a cut off frequency of 0.25 Hz for a window size of 5 s. The calculated drift was subtracted from the original signal after high frequency denoising. A polynomial tting technique as suggested in Ref. [16] was also considered but did not work for signals that show extreme baseline drift. Figure 3 shows an example of a denoised signal with its drift estimation, and the ltered signal.

Fig. 1. Typical Lead I ECG wave showing the features of interest: Q, R, S, REF (reference point), J point and ST segment.

using a combination of traditional time-domain and KarhunenLoeve transform-based approaches (sensitivity/positive predictivity of 81.3%/89.2%).11 Andreao et al. used original markovian 2.3. High Frequency Denoising approach for online beat detection and segmentation, and idenPower interference of 50 Hz and other high frequency noise was tifying ischemia in real-time. (83% sensitivity and Delivered 85% positive by Ingenta to: eliminated using a Butterworth 6th-order low-pass lter with a predictivity).12 Guest User cutoff frequency of 18 Hz. This frequency was determined by Drana et al. proposed a mixture of time-domain analysis and IP : 39.48.158.232 trial-and-error and was found to be appropriate for the purpose machine learning techniques for ischemia detection in real-time Jul 2012 (sensitivity and positive predictivity of 83.33% Sat, and 07 77.31%, of 09:21:16 the proposed algorithm. Figure 4 shows an example of a raw respectively).13 Jeong and his group introduced the idea of refand a ltered signal. erence ST set, where they compare each ST segment with preset With this low-pass lter, there is a signicant distortion in morphologic descriptors and detect any deviations in real time.14 magnitude of R complex (Fig. 4). This ltered signal is only used Other suggested algorithms used similar approaches but they are to elicit the time indices for the features of interest (Q, R, S, J, still far from a desired detection rate, hence, further investigation REF). The actual magnitude of these features will be extracted is needed towards a comprehensive ST-segment analysis for the from the raw signal (measured from the reference point REF) to real-time detection of MI. avoid any information loss in the process of ltering. In this paper we propose a simple clinically-directed digital 2.4. Feature Extraction signal analysis approach towards building an automatic system for real-time detection of MI. R-complex time index detection: After ltering the signal, R complexes time index are rst detected in the following way: (1) As a calibration stage, ve highest-magnitude local max2. METHODS ima are detected during a period of 10 s (to allow for extreme ECG signals are the surface recordings of electrical activity of the cases of tachycardia and bradycardia). This step allows the algoheart through skin attached electrodes. The acquisition of data is rithm to set a threshold of magnitudes to detect the subsequent routinely done in the intensive care and cardiology units. HowR peaks. ever, raw signals are of no use to cardiologists and other physi(2) We dene the detection threshold to be equal to 70% of cians. These signals have to be ltered rst for high frequency average of the amplitude of the rst 5 detected R complexes. noise and low frequency drift in order to be diagnostically use(3) We used ndpeaks command in matlab to detect the subful. The ltered signals are then used for feature extraction and sequent R peaks with threshold set using the values of the diagnosis. The following proposed algorithm was programmed 5 detected R peaks in step 2 above. using Matlab. Lead I data was used for the feature extraction (4) For windows of 5 s, R-peaks are detected if their magnitudes and the time indices of the detected features were used to nd are larger than the calculated threshold. points in the other 11 Leads. Q and S time index detection: Q and S are simply dened A summary of the proposed algorithm is shown in Figure 2. as rst negative peaks encountered on each side of the detected The algorithm consists of 3 stages: ltering, detection, and clasR waves. sication. We used Lead I signal for the detection of the time J-point time index detection: J point is dened as the rst indices for the required ECG features. These time indices were point where the signal levels off (rst derivative = 0, negative then used to extract the ST segment deviation magnitude from second derivative) after S wave. 11 leads. These data were then classied according to the clinical Reference point detection (REF): For the purposes of ST segguidelines and a MI detection was then made accordingly. ment analysis, the reference point is dened by clinicians to be 2.1. ECG Database the PQ segment. The reference point is found in our system as the rst point to the left of Q where the rst derivative equals ECG recordings were obtained from Physikalisch-Technische zero, and the second derivative is negative. Bundesanstalt (PTB) diagnostic ECG database.15 We used PhysFigure 5 shows an example of raw signal and the detected ioNet signal converter to download signal data to Matlab matrix format. features using the proposed algorithm. 226

J. Med. Imaging Health Inf. 1, 225230, 2011

RESEARCH ARTICLE

Filtering

Fig. 2.

ST segment analysis: After time indices of features of interest are detected, they are used to elicit the actual data from the raw signal. The ST segment is assessed clinically using a point 80 ms after the J point for each cycle of heart activity. The magnitude difference between this point and the

Classification

Feature Detection

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Flow chart showing the proposed algorithm for the processing, detection and classication of the ST segments.

reference point is measured for each cycle and saved for diagnosis. ST segment is further analyzed for curvature, a concave upward or at (second derivative <= 0) is considered diagnostically signicant, while a convex ST segment is considered insignicant. 227

RESEARCH ARTICLE
1.5

J. Med. Imaging Health Inf. 1, 225230, 2011

Voltage (mV)

1 0.5 0 0.5 0 1 2 3 4 5 6 104

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1.5

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Fig. 3. An example of baseline wandering removal showing (a) raw signal from Lead I (b) ltered signal.

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2.5. Diagnosis Algorithm Guest User After extracting the time index for the features of interest IP : from 39.48.158.232 ltered Lead I data, the proper features were extracted from Sat, 07 each Jul 2012 09:21:16 lead of the raw signal. Leads are then divided into 3 categories according to the affected part of the heart muscle: Group I: Lead I, aVL, V5, V6 Fig. 4. (a) Raw Group II: V1V4 lters. Group III: Lead II, III, aVF To detect Acute MI, clinical guidelines17 state that there should be ST segment elevation at least 0.2 mV (in the precordial leads V1V6) or 0.1 mV (in frontal/limb leads) in at least 2 contiguous (same category) leads. In our algorithm, an elevation of 0.15 mV in the precordial leads and 0.1 mV in the frontal/limb leads were enough to give the optimum diagnoses.

signal. (b) signal after applying high pass and low pass

3. RESULTS AND DISCUSSION

The proposed low-pass-subtraction method is very effective in removing baseline wandering from Lead I. Figure 3 shows an example of the baseline wandering removal in Lead I data. Note the estimated tting line projected in red. This estimation function is then subtracted from the raw signal to result in part b . The issue with the use of 5 s window for baseline wandering removal is the distortion in the end points. This does not form a problem for the current algorithm. However, this might not be optimal for the purposes of representation to the clinical team (e.g., cardiologists) or for using the ltered data for other analyses. One way to resolve this problem is to detect each heart cycle wave (P, Q, R, S, T) as single entities, and then synthesize the signal again to eliminate any discontinuities. The denoising using low-pass lter distorts the magnitude of some features, especially R-waves (Fig. 4, noting the difference due to baseline shift). It is logical to assume that the distorted signal is not efcient for diagnosis, hence, only time index for the features was extracted to ensure best performance of the system as described in II.C). The ST segment elevation/depression was extracted from the original signal without applying the lters. 228

Figure 4 shows also another example of the two lters applied to remove the baseline wandering and the high frequency noise for 3000 ms data. The ltered wave is localized around the 0 mV baseline and is smoother due to the low-pass lter. The proposed method was able to detect the required features for the diagnosis of ST elevation MI. Figure 5 shows an example of 5000 ms signal with the continuous detection of the features (namely Q, R, S, Ref point, and J point).

Fig. 5. An example high frequency denoising and continuous feature detection (a) raw signal (b) after processing and detection.

J. Med. Imaging Health Inf. 1, 225230, 2011

RESEARCH ARTICLE
Another example of a single waveform with the detected features using the proposed algorithm is shown in Figure 6. The proposed algorithm, based on ST segment analysis alone, was able to detect 85% of the patients with MI (sensitivity) and zero false detection (100% specicity) for the 40 patient recordings. The specicity/sensitivity of this system can be individualized for each patient, thus improving the detection rate on case-by-case basis. In comparison with other proposed algorithms,914 our system provides comparable sensitivity with higher specicity although it used different database from the ones used in those papers. Table I gives the list of the patient recordings used for testing the algorithm.

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The ultimate goal of this work in progress is to produce personalized portable systems which can detect MI at its onset and help 0.6 in seeking early medical attention. In this paper, we introduced a computerized algorithm to extract features from the complex 0.4 ECG waves for the purpose of automatic diagnosis. The proposed Delivered by Ingenta algorithm to: detects 85% of MI incidents with no false detection. Guest User The sensitivity can be enhanced substantially by individualizing 0.2 IP : 39.48.158.232 the detection parameters according to the patients medical histories and risk factors, thus, providing them with personalized Sat, 07 Jul 2012 09:21:16 0 diagnostic device. The fact that our program follows a modied version of the 0.2 clinical guidelines for detecting MI is very important in the clinical practice. The thresholds (e.g., for ST deviation) for diagnostic 0.4 decision purposes can be adjusted further based on customized systems and clinical guideline updates. The developed system 0 100 200 300 400 500 600 will be incorporated into a portable system that receives sigTime (ms) nals from wireless electrodes recording ECG signals from the body surface. The data will be analyzed and sent to a medical center for further analysis and telemetric monitoring. This algorithm should further be validated using different available ECG Fig. 6. An example of one beat waveform (a) raw signal (b) post-processing databases and on patient recordings within the clinical settings signal detected feature. in order to prove effective. Current work in our group is focused on including more criteria for detection of other types of MI (non-ST elevation myocarTable I. Random patient recordings for this paper retrieved from physdial infarction (NSTEMI) and also studying the ECG patterns of iobank PTB diagnostic ECG. Patients in red showed false negative different arrhythmias and ways for early detection. results.
(b) Voltage (mV)
MI patients Patient # 5 10 17 19 26 32 37 43 46 52 65 69 74 80 88 93 100 158 139 259 Recording s0101lrem s0042lrem s0075lrem s0058lrem s0088lrem s0115lrem s0120lrem s0141lrem s0184lrem s0190lrem s0221lrem s0284lrem s0239lrem s0315lrem s0343lrem s0371lrem s0399lrem s0295lrem s0223_rem s0495_rem Healthy controls Patient # 284 279 276 267 266 264 214 263 241 277 260 255 252 251 248 247 246 245 244 243 Recording S0552_rem S0534_rem S0526_rem S0504_rem S0502_rem S0500_rem S0436_rem s0499_rem s0469_rem s0527_rem s0496_rem s0491_rem s0487_rem s0506_rem s0481_rem s0479_rem s0478_rem s0480_rem s0473_rem s0472_rem

Time (ms)

4. CONCLUSIONS

Acknowledgment: Authors would like to acknowledge the support of Qatar National Research Fund, National Priorities Research Program for funding this project under Grant No. NPRP-08-093-2-022. Authors would like to thank Dr. Mukesh Nathani, Cardiologist, for the valuable clinical discussions. We would also thank Electrical Engineering undergraduate student Fatima Ali for her help in ECG data preparation.

References and Notes

1. J. Xu, K. D. Kochanek, and B. Tejada-Vera, Deaths: Final data for 2007, Natl. Vital. Stat. Rep. 58 (2010). 2. Cardiovascular Disease Statistics, American Heart Association, http://www. americanheart.org. 3. J. S. Alpert, K. Thygesen, E. Antman, and J. P. Bassand, Myocardial infarction redenedA consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redenition of myocardial infarction. J. Am. Coll. Cardiol. 36, 959 (2000). 4. S. Yusuf, M. Pearson, H. Sterry, S. Parish, D. Ramsdale, P. Rossi, and P. Sleight, The entry ECG in the early diagnosis and prognostic stratication of patients with suspected acute myocardial infarction. Eur. Heart J. 5, 690 (1984).

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5. T. Jernberg, B. Lindahl, and L. Wallentin, The combination of a continuous 12lead ECG and troponin T. A valuable tool for risk stratication during the rst 6 hours in patients with chest pain and a non-diagnostic ECG. Eur. Heart J. 21, 1464 (2000). 6. R. F. Veldkamp, S. Sawchak, J. E. Pope, R. M. Califf, and M. W. Krucoff, Performance of an automated real-time ST-segment analysis program to detect coronary occlusion and reperfusion 29, 257 (1996). 7. B. J. Drew, S. F. Wung, M. G. Adams, and M. M. Pelter, Bedside diagnosis of myocardial ischemia with ST-segment monitoring technology: Measurement issues for real-time clinical decision making and trial design. Journal of Electrocardiology 30, 157 (1998). 8. T. Hilbel, T. M. Helms, G. Mikus, H. A. Katus, and C. Zugck, Telemetry in the clinical setting. Herzschrittmachertherapie & Elektrophysiologie 19, 146 (2008). 9. N. Maglaveras, T. Stamkopoulos, C. Pappas, and M. Gerassimos, An adaptive backpropagation neural network for real-time ischemia episodes detection: Development and performance analysis using the European ST-T database. IEEE Trans. Biomed. Eng. 45, 805 (1998). 10. F. A. Afsar, M. Arif, and J. Yang, Detection of ST segment deviation episodes in ECG using KLT with an ensemble neural classier. Physiol Meas. 29, 747 (2008).

J. Med. Imaging Health Inf. 1, 225230, 2011

11. A. Smrdel and F. Jager, Automated detection of transient ST-segment episodes in 24 h electrocardiogram. Medical and Biology Engineering and Computing 42, 303 (2004). 12. R. V. Andreao, B. Dorizzi, J. C. M. Mota, and J. Boudy, ST-segment Analysis using HMM Beat Segmentation: Application to Ischemia Detection, CinC04, Conf. on Computers in Cardiology, Chicago (2004). 13. G. Y. Jeong, K. H. Yu, M. J. Yoon, and E. Inooka, ST shape classication in ECG by constructing reference ST set. Med. Eng. Phys. 32, 1025 (2010). 14. L. Drana, A. Goni, and A. Illarramendi, Real-time detection of transient cardiac ischemic episodes from ECG signals, Physiological Measurement 30, 983 (2009). 15. R. Bousseljot, D. Kreiseler, and A. Schnabel, Nutzung der EKGSignaldatenbank CARDIODAT der PTB ber das Internet, Biomedizinische Technik, Band 40, Ergnzungsband 1 (1995). 16. V. S. Chouhan and S. S. Mehta, Total removal of baseline drift from ECG signal, iccta, International Conference on Computing: Theory and Applications (2007), pp. 512515. 17. M. G. Khan, Rapid ECG Interpretation, 3rd edn., Humana Press Inc., Totowa, New Jersery (2008).

Received: 30 May 2011. Revised/Accepted: 22 August 2011.

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