Multifaceted analysis of ECG and its

derived parameters for decision

making using Fuzzy logic
S.K. Dinesh Kumar, S.R. Divya,J. Jenifer Vimala,R,J. Sujith

Department of BioMedical, Jerusalem college of Engineering, Chennai-600 100

dinesh.s.k.kumar@gmail.com diviraju22@gmail.com
jjenifer1994@gmail.com sujith.bme@gmail.com

Abstract — Heart rate turbulence (HRT) is the return to equilibrium of heart rate after a premature ventricular contraction.
HRT was calculated using two different parameters such as turbulence onset (TO) and turbulence slope (TS) for the
prediction of mortality. HRV represents a physiological phenomenon which consists in the oscillations in the interval between
consecutive heart beats. The HRV analysis can make an assessment for both stress evaluation and cardiac health. Our project
aims at analysing mental stress during various occasions by comparing to HRV using LabVIEW. HRV parameters such as
mean RR, RMSSD, pNN50 and LF/HF are calculated for mental stress detection. Further a comparative analysis has been
made between normal subjects and apnoeic patients in order to show the variations of parameters.

Keywords: TO, TS, Mean RR, RMSSD, pNN50 and LF/HF

and evaluating the features derived by the individual

I. INTRODUCTION
During past decades, cardiology experts have recognized
important relationships between the autonomic nervous
system (ANS) and cardiovascular mortality. As consequence,
experimental proofs for an interdependence
between a propensity for lethal arrhythmias and signs of
either increased sympathetic or reduced vagal activity have
encouraged the development of quantitative markers of
autonomic activity. Heart Rate Variability (HRV), which
refers an accurate measure in milliseconds in the variation
in the intervals between heartbeats, is one of the most
promising such markers. The HRV analysis is not only a
noninvasive tool for assessing cardiovascular system
function, but is also useful for evaluating the function of
the ANS in regulating human organs and muscles (Lin
et al. 2010). One of the most widely accepted and low-cost
diagnostic procedures useful for deriving and evaluating
the HRV is surely the electrocardiogram (ECG), i.e., a
transthoracic interpretation of the electrical activity of the
heart over time captured and externally recorded by skin
electrodes. Therefore, ECG data are normally acquired for
clinical diagnosis of cardiac function with the aim of
identifying patients at risk for a cardiovascular event or
death (American Heart Association et al. 1996).
With the development of advanced signal processing
methods such as wavelets and fast fourier transform (FFT),
the diagnostic power of the ECG data is strongly increased
due to the huge set of features which can be extracted from
the ECG signal. This expanded set of features enhances the
medical staff capabilities to diagnose the cardiac function
quality of a patient. However, the manual managing of this
expanded set of features by medical staffs results in a very
complex task. As consequence, to support physicians in
their decisional activities, automatic methods for representing
ECG data are necessary.
In this scenario, soft computing techniques and knowledge
representation methods may provide several benefits
both in terms of quality and expressiveness of taken decisions.
Starting from this consideration, this paper proposes
an enhanced ECG-based decision making system useful to
evaluate the cardiac health level of a given person by
combining ontological methodology and a type-2 fuzzy
inference mechanism modeled through the Type-2 Fuzzy
Markup Language (Type-2 FML). In detail, our proposal of
ECG-based decision making system is based on the design
of
1. A complex ontology representing personal HRV
characteristics and all features which may influence
them such as exercise, rest, pressure, disease, and so
on;
2. a Type-2 FML-based fuzzy logic system inferring the
human nervous level with aim of preventing cardiovascular
mortality by analyzing the collected personal
HRV features.
The integration of the three soft computing techniques
(ontologies, type-2 fuzzy inference mechanism and FML)
provides several benefits to our proposal of ECG-based
decision making system. Indeed, our system is able to
1. Improve expressiveness of the medical knowledge by
using a simple representation in the form of the
semantic sentences which may make easier the understanding
of the results of HRV analysis;
2. provide a valid support to medical decisions based on a
type-2 fuzzy inference mechanism capable of modeling
the human reasoning model in a better way than
type-1 inference engines thanks to their capability of
merging the knowledge related to various domain
experts opinions;
3. achieve interoperability feature to implement the same
ontological fuzzy-based application on different hardware
platforms by means of employing the Type-2
FML.
To prove the suitability and good performances provided
by the proposed system, two different kinds of tests,
respectively, based on a qualitative and quantitative
approach, have been led in the experimental section. In
particular, the first one is used to show the feasibility of our
approach for cardiac diagnosis by means of a system
behavioural analysis performed by medical experts. In
detail, after evaluating several decision surfaces representing
system behaviour, medical experts have validated
as corresponding to the real situation, the human nervous
level value (and the related cardiac health) computed by
our system. The second experiment, instead, allows to
effectively quantify the performances of our proposal in
terms of two well-known conformance measures: precision
and recall. In detail, in this second test, our system is
exploited to accomplish a classification task which
involves some students during an exam. The obtained
precision and recall values proves the good performances
of our proposal.
A. HEART RATE TURBULENCE
Heart rate turbulence (HRT) is the return to
equilibrium of heart rate after a premature ventricular
contraction (PVC). It consists of a brief speed-up in heart rate,
followed by a slow decrease back to the baseline rate. An
important feature of HRT is that PVCs occur naturally in most
adults, so measuring the characteristics of a given person's HRT
offers a non-invasive way to evaluate his or her cardiac function
without applying artificial external stimuli.
The values of HRT parameters have to be a statistically
significant predictor of the probability of dying from cardiac
disease after a patient suffers amyocardial infarction. HRT can
also be used to predict death in patients with congestive heart
failure from a lethal arrhythmia. HRT has nothing to do
with turbulence in fluid dynamics.
B.SLEEP APNEA
Sleep APNEA is a disorder characterized by a reduction
or pause of breathing (airflow) during sleep. It is common among
adults becoming more common in children. Although a diagnosis
of sleep APNEA often will be suspected on the basis of a
person's medical history, there are several tests that can be used
to confirm the diagnosis. The treatment of sleep APNEA can be
either surgical or nonsurgical.
An APNEA is a period of time during which breathing
stops or is markedly reduced. In simplified terms, an APNEA
occurs when a person stops breathing for 10 seconds or more. If
a person stops breathing completely or take less than 10% of a
normal breath for a period that lasts 10 seconds or more, this is
an APNEA. This definition includes complete stoppage of
airflow. Other definitions of APNEA that may be used include at
least a 4% drop in oxygen in the blood, a direct result of the
reduction in the transfer of oxygen into the blood when breathing
stops.
During sleep, the brain instructs the muscles of breathing to take
a breath.
 Central sleep APNEA (CSA) occurs when the brain
does not send the signal to the muscles to take a breath
and there is no muscular effort to take a breath.
 Obstructive sleep APNEA (OSA) occurs when the
brain sends the signal to the muscles and the muscles
make an effort to take a breath, but they are
unsuccessful because the airway becomes obstructed
and prevents an adequate flow of air.
 Mixed sleep APNEA, occurs when there is both central
sleep APNEA and obstructive sleep APNEA.
.
C.HEART RATE VARIABILITY
Heart rate is the number of heart beats per unit time,
typically expressed as beats per minute (bpm). Heart rate
variability (HRV) is a physiological phenomenon which analyses
how the RR intervals, changes over time. HRV varies for
different orthostatic positions like supine and standing positions.
An indirect measurement from the ECG signal is the HRV. HRV
analysis provides a quantitative marker of the autonomic nervous
system (ANS) because the regulation mechanisms of HRV
originate from sympathetic and parasympathetic nervous system.
D.AUTONOMIC NERVOUS SYSTEM
The Autonomic nervous system (ANS) is the part of
the peripheral nervous system that acts as a control system,
functioning largely below the level of consciousness, and
controls visceral functions. The ANS affects heart rate, digestion,
respiratory rate, salivation, diameter of pupils, micturition
(urination) and sexual arousal. Whereas most of its actions are
involuntary, some such as breathing work in tandem with the
conscious mind.
It is classically divided into two subsystems:
Parasympathetic nervous system (PSNS) and sympathetic
nervous system (SNS) have shown in figure1.1. With regard to
function, the ANS is usually divided into sensory and motor
subsystems.
II. HRV Measurement Using Conventional Methods
The clinical use of heart rate variability analysis is
widespread as ECG data are sufficient for further analysis, thus
providing a non-invasive method in the assessment of autonomic
activity. It is notable that the RR-intervals, being only an aspect
of the whole ECG data set, contain such relevant information
about the functioning of the autonomic nervous system.
There are two main methods for quantifying heart rate
variability. They are:
 Time domain methods
 Frequency domain methods
 The basis of all methods is a tachogram, where the RR-
intervals are plotted against the beat number. The fluctuating
heart rate becomes visible as a time series shown in fig 3.6.

Fig. 1 RR-interval tachogram

A. Time Domain Analysis

The time domain methods include standard statistical

methods such as calculating standard deviations (SDNN [ms]) or
graphing density distributions of successive RR-intervals. HRV
triangular index (HRV-TI) is a standard measure that helps to
discriminate normal from reduced heart rate variability. It can be
obtained by dividing the total number of RR-intervals by the Fig. 2 Power spectrum analysis of heart rate time series
number of RR-intervals with the value that has been counted to
Power spectral density (PSD), using parametric or
be most frequent in the total RR-interval series.
nonparametric methods, provides basic information on the power
distribution across frequencies. Fig. 1.3 shows the power
B. Frequency Domain Analysis
spectrum analysis of a heart rate time series. One of the most
The frequency domain analysis is used to identify the commonly used PSD methods is the Discrete Fourier Transform.
underlying rhythms of heart rate time series. They represent Methods for the calsulation of PSD may be generally classified
different oscillating physiological processes. Applying the Fast as nonparametric and parametric. In most instances, both
Fourier Transform (FFT) to the heart variability signal, the signal methods provide comparable results.
is decomposed in its constituent harmonic frequency
components. A power spectral density graph shows how the total The advantage of the nonparametric methos are
power, usually indicated as power spectral density measured in
ms2 is distributed as a function of the various frequencies  Simplicity of the algorithm used
measured in Hertz (HZ). The power corresponds here to the  High processing speed
variance of the signal at certain frequency shown in fig 3.7.
The advantage of parametric methods are

 Smoother spectral component that can be distinguished

independent of preselected frequency bands.
 Easy post processing of the spectrum with an automatic
claculation of low and high frequency power
components with an easy identification of the central
frequency of each component
 An accurate estimation of PSD even on a small number
of samples on which the signal is supposed to maintain
stationarity.

The basic disadvantage of parametric methods is the need of

verification of the suitability of the chosed model and of its
complexity.
  The HF power spectrum is evaluated in the range
from 0.15 to 0.4 Hz. This band reflects
parasympathetic tone and fluctuations caused by
spontaneous repiration known as respiratory sinus
arrhythmia.
 The LF power pectrum is evaluated in the range
from 0.04 to 0.15 Hz. This band can reflect both
sympathetic and parasympathetic tone.
 The VLf power spectrum is evaluated in the range
from 0.0033 to 0.04 HZ. The physiological
meaning of the band is most disputable. With
longer recordings it is considered representing
sympathetic tone as well as slower humora and
thermoregulatory effects. There ae some findings
that in shorter recordings VLF has fair
representation of various negative meotions,
worries, rumination etc.
 The TP is a net effect of the possible
physiological mechanisms contributing in HR
variability that can be detected in 5-mins
recordings, however sympathetic tone is
considered as a primary contributor.
 The LF/HF ratio is used to indicate balance
between sympathetic and parasympatheic tone. A
decrease in the score might indicate either
increase in parasympahtetic or decrease in
sympathetic tone. It must be considered together
with absolute values of both LF and HF to
determine what factor contributes in autonomic
imbalance.
C.Non-linear methods
Given the complexity of the mechanisms regulating
heart rate, it is reasonable to assume that applying HRV analysis
based on methods of non-linear dynamics will yield valuable
information. The most commonly used non-linear method of
analysing heart rate variability is the poincare plot. Each data
point represents a pair of successive beats, the x-axis is the
current RR-interval, while the y-axis is the previous RR-interval.
HRV is quantified by fitting mathematically defined geometric
shapes to the data. Other methods used are the correlation
dimension, nonlinear predictablility, point wise correlation
dimension and approximate entropy. Detrended fluctuation
analysis is also a non-linear method used.
D. Quantification and measurement of HRT
The HRT pattern is frequently masked by heart rate
variability (HRV) of other origins. Thus, averaging responses to
a number of VPCs is needed to characterize the pattern
accurately. Consequently, HRT is usually assessed from Holter
recordings as an average response to VPCs over longer periods .
From such recordings, the so-called VPC tachogram is
constructed, aligning and averaging the R-R interval sequences
surrounding abefore VPCs, the coupling interval and
compensatory pause, and at least 15 subsequent sinus R-R
intervals. The average needs to include a sufficient number of
VPCs for reliable construction of the VPC tachogram. Studies
involving only very short Holter recordings may not lead to
meaningful results .
Two phases of HRT, the early sinus rate acceleration
and late deceleration, are quantified by 2 parameters termed
turbulence onset (TO) and turbulence slope (TS). Turbulence
onset is calculated
as:TO=(RR1+RR2)−(RR−2+RR−1)(RR−2+RR−1)×100 [%]TO=
(RR1+RR2)−(RR−2+RR−1)(RR−2+RR−1)×100⁢ [%] where
RR−2 and RR−1 are the 2 R-R intervals immediately preceding the
VPC coupling interval, and RR1 and RR2 are 2 R-R intervals
immediately following the compensatory pause . Turbulence
slope is defined as the maximum positive regression slope
assessed over any 5 consecutive sinus rhythm R-R intervals
within the first 15 sinus rhythm R-R intervals after the VPC .
E. HRT Calculation
Calculation of the HRT parameters turbulence onset
(TO) and turbulence slope (TS). Turbulence onset is the relative
change of R-R intervals (red lines) from before to after the VPC.
Turbulence slope is the slope of the steepest regression line fitted
over the sequences of 5 consecutive sinus rhythm R-R intervals
within the 15 R-R intervals after the VPC. The light blue
lines are the 11 possible regression lines. The dark blue line is the
steepest one used for TS calculation shown in fig 3.9.
Fig. 3 TS Slope Calculation
Hence, in normal subjects, the initial brief acceleration of sinus
rate after the VPC is characterized by negative TO, and the
subsequent rate deceleration is characterized by positive TS.
\
III. STRESS ANALYSIS
The ECG is acquired from different subjects and there
stress level is analyzed using the fuzzy logic. The stress level was
found to be extremely varying based on age. The performance of
the subjects higher on age were found to be distinct from the
performance of young aged subjects. From which we were able
to predict the association of ECG wave as a function of stress.
A feedback for the nervous patients has been provided
with a musical therapy and the comparison of their parameter are
tabulated below.
 TO values will be lesser than zero and TS will be greater than
Table 1 Time-domain and frequency-domain parameters for 2.5.
nervous subjects
Tabulation of TO and TS
Before musical therapy After musical therapy
Subj RR RM PN LF/ RR R PN LF
ects - SS N5 HF - M N5 /H SUBJECT TURBULENCE TURBULENCE
ME D 0 M SS 0 F ONSET RATE
AN EA D SUB1 -8 3.99
N SUB2 -10 4.09
SUB 0.2 92. 33 1.1 0.5 35. 35 1.4 SUB3 -8 4.096
6 6 84 18 72 15 56 SUB4 -5 3.093
SUB 0.2 238 73. 0.8 0.7 80. 60 2.0
7 07 .11 3 17 22 54 12 SUB5 -11 4
SUB 0.1 234 83. 0.8 0.6 85. 55 1.1 SUB6 -5 3.98
8 9 .28 33 5 54 78 18 SUB7 -3 3.96
SUB 0.2 158 56. 0.6 0.5 48. 28 1.3 SUB8 -10 3.97
9 8 .28 66 20 66 41 22
SUB9 -4 3.05
SUB 0.3 266 63. 0.5 0.4 10 29 1.9
10 4 .98 33 37 56 3.5 02
1 Table 3 HRT analysis

VI. FUTURE SCOPE OF THE PROJECT

IV. ANALYSIS OF SLEEP APNEA
HRV characterization can be taken as a parameter for
Sleep APNEA is a serious sleep disorder that occurs the analysis of the mortality rate in the post myocardial infarction
when a persons breathing is interrupted during sleep. It normally patients, in stress management as a feedback, in assessing cardiac
occurs for higher aged peoples. The mean of RR-interval and abnormalities, for diagnosing cardiac abnormalities in smoking
pNN50 for apnoeic subjects is very low when compared to and non smoking persons.
normal subjects. And LF/HF for apnoeic subject is very high
when compared to normal subjects Although all of our participants had normal findings on
ECG we cannot rule out the presence of any cardiovascular
SUBJECTS MEANR- RMSSD PNN50 LF/HF disease entirely. HRT characterization can be used for analysis of
R the mortality rate after a premature ventricular contraction
SUB 1(ab) 0.09 3.4 0 67.5 (PVC). Other than ECG, PPG signal can also be used to the
evaluation of HRT which is more convenient to use under
SUB 2(ab) 0.097 6.4 0 85 various occasions.
SUB 3(ab) 0.09 1.6 0 36
SUB 4(ab) 0.078 1.24 0 58
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