Proceedings of the 25" Annual International Conference of the IEEE EMBS Cancun, Mexico September 17-21,2003

A Spatial Study of the ST Segment

R. Gonzalez', M. Caiiizares', G. Rodriguez', G. Meisijimilly

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'Medical Devices Division, Central Institute of Digital Research, Havana, Cuba

Abstruct- A new method for real-time spatial ST segment evaluation was developed and preliminarily tested with three stress electrocardiograms and five long-term rest electrocardiograms. The classic Function of Spatial Velocity was modified in order to improve the performance of the QRS complexes onset and offset identification; this function was computed for three groups of leads and identification thresholds were set up for each group. QRS complexes were classified as non-premature and premature according to the complex width and the RR interval duration. To avoid wrong ST measurements on the first branch of the T wave, an inverse relationship was set between the average RR interval duration and the distance since the J-point to the ST segment middle point. Vectors associated to leads 11, V1 and V5 were considered like the axes of an orthogonal system and the ST deviation for each lead Like the projections of the ST vector. The vector module was computed for non-premature complexes according to the classic expression and its value showed an earlier sensitivity to ST pathological changes than the traditional lead by lead study. The proposed method was tested with 10758 beats, all of them were detected and never a premature beat was misclassified. ST measurements never were made in the first branch of the T wave.

ST measurements over the T wave are frequent when the heart rate is high. A method to study the ST segment must avoid this situation. The ST segment iind all the electrocardiographic parameters should be anzlyzed from a spatial point of view because the heart is a volumetric organ and the electrocardiogram is composed by different points of view (leads) of its electrical activity. The researchers, since Einthoven to the present, have made continuos effort in order to detect the first signs of an abnormal situation. The aim of this paper is to show a method developed by the authors in order to measure the ST segment and to study this parameter since a spatial point of view in real time.

11. METHODOLOGY

Keywords-ECG,

QRS complexes, ST segment

I. INTRODUCTION Nowadays, the ST segment is the most important noninvasive indicator to detect ischemic disturbances [ 11. This segment has been studied since the beginning of the electrocardiography because cardiac diseases are one of the main causes of death in the world and ischemic disturbances are one of the most important cardiac diseases [2]. The stress test systems have been designed and improved to study the ST segment evolution when the patients are making physical efforts (bicycle or treadmill) and modern monitors are able to make a real-time ST segment study in order to alert about cardiac complications in Intensive Care Units, Coronary Care Units, ambulances, etc. Many algorithms have been developed to study the ST segment [3] [4], but a standard method has not been found and researchers are looking for better solutions every day. The main problems to solve are the following: A good estimation of the baseline is needed to measure ST segment deviation because this is the measurement reference. 0 ,The QRS complex offset identification should be reliable because QRS width is used to make the complex classification. Also, the J-point could be used to compute the ST slope.

The proposed metho'd starts with the ECG analogue to digital conversion procesa. The independent leads (I, 11, V1, V2, V3, V4, V5, V6) are sampled simultaneously at a rate of 250 Hz; leads 111, aVli, aVL and aVF are computed according to classic expressions based upon leads I and 11. The next step is to apply a digital moving-average filter proposed by Ligtenberg [5] with a bandpass between 0.6 and 37 Hz in order to r'emove electromyographic artifacts and to avoid baseline wander. A notch filter is also used to reject the 60 Hz interference. The Function of Spatial Velocity (FSV) is used as an auxiliary function for QRS complex detection [6]. It is computed sample by sample and its value is compared with a threshold in order to know if the studied sample belongs to a QRS complex. The authors of this paper introduce the following modifications to improve its results: 0 Electrode status is included in the FSV expression in order to cancel those leads with poor electrode contact. 0 The FSV is computed for three lead groups (I, 11, III; V1, V2, V3; V4, V5, V6) in order to get betters results for the onsedoffset ]identification process because it is very important to class. This modification avoid the influence of some pathologies, mainly branch blocks, in a unique QRS width computed for the twelve leads. 0 The QRS complex identification is based on a majority rule. A QRS complex is detected when it is true for two or three FSV. A pair of threshold:; is set up for each FSV: a QRS frontier threshold and a QRS onsetjoffset threshold. An example of FSV for the eight independent leads is shown in Fig. 1. The modified FSV, computed for each defined lead group, has the same shape than the original FSV, but its values are smaller because it is based only on

0-7803-7789-3/03/$17.0002003 IEEE

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three leads. It is very important because the overflow error probability will be not significant. The modified expression for the FSV is shown in (1).

i=l

where: FSVLj]: Function of Spatial Velocity for sample j, x[i,j]: value for lead i at instant j, elect: electrode status (connectednot connected), N: lead quantity. The QRS complex detection has two phases: leaming and detection. The leaming phase requires five seconds to initialize parameters and detection thresholds based upon signal characteristics and events detected during this process.

periodically. A QRS complex has been detected when its width is greater than 30 ms and its previous RR interval is greater than 200 ms; these are physiological limits. Each QRS complex is classified like a Premature' Ventricular Complex (PVC) or non-PVC because ST segment should be measured in non-PVCs only. The complex classification process was based upon QRS duration, QRS complex prematurity (previous RR interval little than 75% of the mean RR interval duration) and a Difference Area Function which is computed for each QRS complex detected in order to know if the studied complex is similar to the non-PVC pattem. This pattem is created in the leaming phase and it is updated with the classified complexes. The Difference Area Function is described in (2).

i=l

I1

U1 U2

U3

where: DAF[i] The Difference Area Function for any sample, p[i]: A value of the non-PVC pattem, w: The width of the non-PVC pattern, x[i]: A sample of the QRS complex studied. A QRS complex is classified as a non-PVC when it is a non-premature complex, its duration is greater than 85% of the mean QRS duration and less than 110% of the mean QRS duration, and its difference area value is greater than 85% when is compared with the non-PVC pattem. The baseline is very important to measure the ST segment deviation because it is the reference to do that. Baseline is estimated like the mean value of the onset for the last three non-PVC complexes; this process is made for each lead. The middle point of the ST segment is set according to a relation between the mean RR interval and the distance since the J-point to the sample where de ST segment deviation will be measure. It is made to avoid a measurement over the first branch of the T wave. The ST segment deviation is computed for leads 11, V1 and V5 and the module of the ST vector is computed according to (3). (3) where: ST,[i]: ST vector module for sample i-th, STll[i]: ST segment deviation for lead 11, STvl[i]: ST segment deviation for lead V1, STvs[i]: ST segment deviation for lead V5.

<

U4

U5
U6

L FSUIZjo

>

F SU
Fig. 1. An example of the Function of Spatial Velocity based upon the eight independent leads.

The learning phase is followed by the detection phase where QRS complexes are identified and thresholds are adjusted periodically in order to adapt to changing characteristics of the ECG. Also, QRS width and RR intervals are measured, a mean value was computed for each one. A threshold is used to define if the studied sample is inside a QRS complex candidate or not. The second threshold is applied to identify QRS complex onset/offset. Both thresholds are computed for each FSV because some pathologies like ventricular blocks can introduce differences in QRS width for leads associated to different heart sides. The RR interval is measured for each QRS complex detected; this interval is defined like the distance between the R wave peak for two consecutive QRS complexes. The R wave peak is defined like the maximum positive value inside a QRS complex for lead 11. An average is computed

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To compute (2), leads 11, V1 and V5 are considered like the axes of an orthogonal axis system and the ST deviation values like the projections of the ST vector. For each nonPVC ST vector module is computed and this value is checked against a threshold to detect a hazardous situation. The proposed method was tested with three digital stress test and five ten-minute rest ECG strips. Two stress tests had a ST segment evolution toward pathologic status and the third test was normal. Pathologic ST segment deviations were not present in the rest ECG strips studied. The digital stress tests were made with a computer-based system and the rest ECG strips were made with a digital electrocardiograph [7]. Both devices were designed and produced in Cuba. 111.

personal computer screen. The permitted error was set to 12 ms. This error is equivalent to 0.30 mm when the chart speed is 25 /s and it is impossible to distinguish by a human observer. The onsedoffset identification in these complexes was considered as enough for the proposed method goals. The ST segment deviation measurement never was made on the I wave; heart rate reaches 160 beat per minute in some phases of the studied stress test. A summary of these results is shown in Table 111.
TABLE I11
ACCURACY OF THE QRS WIDTH MEASUREMENT

RESULTS

Total coincidence Error less or equal than 5 ms Error greater than 6 ms and less than 10 ms Error greater than 10 ms Total

Total 48 126 22 4 200

24 63 11 2 100

More than 10,000 beats were studied as illustrated in Table I. Two cardiologists classified these beats like normal, ventricular or atrial QRS complexes and their classification was used as a golden rule to evaluate the proposed method, this process was made off-line. They were aided by a computer program, developed by the authors of this paper, with a graphic interface that allows a detailed study of the digital ECG recorded by the digital devices used in the test.
TABLE I QRS COMPLEXES STUDIED Total 10397 361
0

ST vector module kept a stable value when dangerous ST segment deviations were not present. However, the ST vector module showed an earlier sensitivity to ST pathological changes than the traditional lead by lead study when an abnormal situation was present. It was observed in the studied stress tests. IV. DISCUSSION

Normal Ventricular Premature Atrial Premature Total

96,64 3,36

0,oo
100,oo

The QRS complex detection performance was successful. In fact, all QPS complexes were detected. These results have been reported in previous papers by the authors
[71

10758

PI.

All QRS complexes were detected and False Positives (FP) were not present. This process was not influenced by the type of QRS complexes studied. The QRS complex classification performance is illustrated in Table 11. . TABLE 11 QRS COMPLEX CLASSIFICATION Total 10389 0
8 369 10758

Normal identified False Positives False Negative Ventricular Premature Total

A total of 99,92% of normal complexes were wellclassified and never a ventricular complex was classified as normal. Eight normal, complexes were misclassified. Six errors were due to Rk interval that satisfied the prematurity criteria and two errors were associated to the QRS width criteria. All the ventricular premature beats were identified and False Positives were not present. In order to test the reliability of the QRS width measurement process, two hundred QRS complexes were randomly selected and measured with graphic tools on a

The use of three auxiliary functions for the QRS complex detection improved the complex onsetloffset identification accuracy. Also, ST segment deviation measurement was better because the J-point identification was better and the baselime estimation was better too. If a unique FSV is used to estimate onsetloffset, the method will be prone to errors when some pathological conditions are present in the ECG [8]. The best example is the left or right branch block because they modify the QRS width in some leads according to the affected ventricular branch [7]. The proposed complex classification process is easy because only integer a,perations are needed. However, results are satisfactory, never a ventricular beat was classified like a normal beat and always ST measurements were made in the right complex. Eight normal QRS complexes were misclassified, but this number is not significant when it is compared with the studied beat count. The dynamic selection of the sample to measure the ST deviation is very important [7]. In fact, never the ST deviation measurement was made on the T wave because of the relation that the method set between the mean RFt interval duration and the distance since the J-point to the sample where ST deviation is measured. With this kind of

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relation a classic error for high heart rates has been eliminated. The ST vector study shows interesting results. The vector module value showed a stable performance when the ECG is normal and it was highly sensible when an abnormal situation was starting. In fact, the proposed method sensitivity was greater than the traditional method sensitivity when an ischemic disturbance started to develop. This characteristic is very important for heart attack monitoring because the first minutes in this kind of situations are very important in order to reduce the patient damages.

V. CONCLUSION

A new method for real-time spatial ST segment study have been developed and tested successfully. The method was tested with more than 10,000 beats and all of them were detected. The QRS classification process is easy and its performance is successful; a ventricular complex never was classified like a normal complex and only eight normal complexes were misclassified. The modifications made to the classic FSV improved the onset/offset identification process and the method overall performance. The vector module always was computed for nonpremature complexes and its value showed an earlier sensitivity to ST pathological changes than the traditional lead by lead study. The proposed method seems useful as a tool to monitor ST segment deviation in order to make an earlier ischemic disturbance detection than traditional lead by lead observation.
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A. A l g a &.al. QT interval variables from 24 hour electrocardiography and the two year risk of sudden death. British Heart Journal; vol. 70: pp. 43-48. 1993. J. Schaldach. Heart Electrotherapy. Library of the Congress. Catalog Card Number: 93-72132. 1993. R.Jane, A. Blasi, J. Garcia, P. Laguna. Evaluation of an Automatic Threshold Based Detector of Waveform Limits in Holter ECG with the QT Database. Computers in Cardiology; vol. 24:pp. 295-8. 1997. [41 F. Jager; G. B. Moody; A. Tadder. Performance Measures for Algorithms to Detect Transient Ischemic ST Segment Changes. IEEE Computers in Cardiology. IEEE Computer Society Press. pp. 369-372. 1991. A. Ligtenberg, K. Murat. A Robust Digital QRS Detection Algorithm for Arrhythmia Monitoring. Computer and Biomedical Research; vol. 16: pp. 273-86. 1983. P. W. Macfarlane, D. K. Macfarlane, M. Podolski. Mingocare: A new program for automated electrocardiogram interpretation. Electromedica vol. 52, No. 4, 1984. R. Gonzllez, M. Rivero, R. Femlndez. Evaluation of a Program for Automated Electrocardiogram Interpretation. Virtual Cardiology Congress. Argentina, 2000. R. Gonzllez, R. FemBndez, M. Raola. Real-Time QT Interval Measurement. World Congress on Medical Physics and Biomedical Engineering. Chicago, 2000.

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