Cardiac Monitoring

Part 1: Jan 19, 2021

B ECG
PRESSURE EEG
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Patient Monitoring Systems
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RESPIRATION O ! HEARTBEAT (
PULSE

Objective: quantitative assessment of important physiological variables during critical periods of

biological function

We want to know:
(1) actual value
(2) trend of change

Continuous monitoring vs. regular intervals

EG .
Ian HB E.
! Montes BP

Long-term goal of patient monitoring systems: decrease mortality and morbidity by ...
(1) organize and display info for improved patient care
(2) correlates multiple parameters
(3) processing data to set alarms for some conditions
(4) providing info regarding therapy
(5) ensuring better care with few staff members

Common parameters to assess:

ECG, heart rate, pulse rate, pulse ox, BP, body temp, respiratory rate

Cardiac Monitor
Heart is the most important physiological parameter to be monitored in the ICU.
Specifically: heart rate & shape (morphology) & the ECG waveform

Names: cardiac care units, coronary care units (CCUs), cardiac monitors, cardioscopes
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DISPLAY BEEPIUGHT SYSTEM

(CRT / LCD )
 Today, most systems are digital and required ADC among other components.

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Parameters we control when designing a digital system:

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( AMPLITUDE RESOLUTION)
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How do we choose sample rate?

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Hz =

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For monitoring, the bandwidth of the ECG signal is 50 Hz.
Nyquist theorem:
Considering a signal that has a maximum frequency component of X, you can perfectly recreate
the signal if you sample at 2X.
Thus, we can recreate the ECG signal if we sample at 50x2 = 100 Hz.
Textbook: 150 Hz is sufficient (3x50 Hz)
Most systems sample at 250 Hz
American Heart Association: 500 Hz (diagnostic cases)

How do we choose word length?

Before ADC: signal is amplified to be between 0 and 1 V.

Greater bits/word —> improved resolution
8 bits is common: 2^8 = 256 possible values.

How do we choose memory capacity?

Example:
- 5 seconds of data
- 13 cm

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- spot moves at 25 mm/s
- 200 samples/s

How many words do we need?

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200 SAYLE x
5 s =

1,000 samples i'→

( WORDS)
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Modern systems use LCD screens, not cathode ray tubes (CRTs).

Frequency response: there are two modes for frequency response:

(1) Monitor mode: bandwidth 0.4–50 Hz.
(2) Filter-in / Diagnostic mode: bandwidth 0.05–100 Hz

Some systems have a 50 Hz notch filter to improve the common mode rejection ratio.

Electrosurgery Interference: RF interference occurs with two possible modes: (1)

conduction - RF energy is carried through the patient into the monitor. (2) radiation - RF
energy is carried through the air and is induced into the circuits of the instrument, leads,
and cables.

Leads off detection: loss of body contact (RA or LA electrode) causes a high impedance
change at the electrode/body contact surface —> loss of bias at the appropriate amplifier
input —> amplifier saturates —> produces maximum amplitude waveform —> threshold
A-NAMES
alarm is set off my the maximum amplitude waveform.
REST of SYSTEM
\
SPANS

STORES # DATA

Integrated Circuit (IC) TRANSMITS

TI ADS1298 AFE Digitizes SIGNAL

- 12 lead
- analog front-end
- 24-bit ADC
Part 2: Jan 25, 2021

Bedside monitors:

III
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- displays ECG waveform
- blood pressure
- pulse Microcomputers
- heart rate t
- temperature
TOUCHSCREEN
- respiration rate

PREAMP
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DISPLAY

Trends in bedside monitoring: Software-based!!!

- system updates are easier (replace a memory chip)
- sophisticated signal processing tasks
- new algorithms to calculate cardiac indices (detect conditions)
- filter and condition signal digitally
- touch screens (user-friendly)

Design specifications:
- portable, flexible (used in many settings)
- capability
- power consumption
- system versatility
- ease of use
- easy data transfer (Bluetooth, WiFi, Zigbee) (also consider storage)
- easy to maintain
 Measuring the Heart Rate
HR is derived by the amplification of the ECG signal and by measuring either
I theit
average orm
instantaneous time intervals between successive R peaks
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Average calculation does NOT represent the true picture of the heart’s response to
different conditions. (Example: exercise)

Instantaneous (beat to beat) calculation gives a true picture of the heart rate ONLY
right now.

Combination method: beat-to-beat with averaging (4 - 6 beat average). This gives a

clearer picture of the heart’s CURRENT condition (compared to averaging) but also
robust enough to filter out noise.
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We must be able to detect HRs between ________ and250
_______ BPM

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Problem: heart rate detection depends on reliable QRS complex detection, ECG
signals can be noisy, making QRS complex detection difficult. (Example:
patient movement —> muscle signals —> picked up by electrodes)

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Refractory period: period of time after a heart beat is detected where

any other potential heart beat is rejected (NOT a heart beat).

Common refractory period for heart rate detection: 200 ms

What is the fastest heart ÷s = 5 Hz

rate detectable with a 200
ms refractory period?
5pBY x

6,0÷ =
300 BPM

6.dz ⇐ 300 BPM

Based on power spectra estimation of the QRS complex, a bandpass filter

with center frequency 17 Hz and Q = 5 yields the best SNR

Q -100
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17 Hz f
Part 3: Jan 26, 2021

Arrhythmia - any disturbance in the heart’s normal rhythmic contraction

Arrhythmia ALWAYS appears, in some way, in the ECG waveform.

How?
(1) morphological statements - ECG waveform shape can describe the state of the
working muscle mass (heart)

(2) rhythm statements - site and rate of the cardiac pacemaker and the
propagation of impulses through the conduction system
STARTS IN AN ABNORMAL LOCATION
# BEAT THAT
Ventricular ectopic beat AKA
(
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PREMATURE VENTRICULAR CONTRACTION PUC)

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↳ LOCATION
IRRITATION IN THE VENTRICLES → THE SELF TRIGGERING
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Arrhythmia monitor
- fancy, complicated alarm system
- constantly scanning the ECG signal for signs of arrhythmia

Detect:
- premature QRS complexes
- widened QRS complexes
- runs (repeating) of widened QRS complexes

Every patient’s ECG will look different —> Thus, the template for QRS and other
ECG waveform morphologies is built from the patient’s own ECG.

1) the system stores a normal QRS for reference (visually examined by a

physician to determine if it’s truly normal)
2) initiates an alarm automatically whenever ectopic beats are detected
3) alarm lights when they (ectopic beats) are detected at frequencies >6/
minute, or 12/minute
4) detects and trigger alarm when artifacts are present at the source
 Signal conditioning - amplify, filter (0.05 - 100 Hz for diagnostics, 1-40 Hz for
monitoring), digitize (ADC) using 8- or 12-bit ADC (typically has a sample rate of
250 Hz)

Noise Detection - signal processing can remove noise such as baseline wander or
motion artifacts
LOW FREQUENCY
QRS detection - arrhythmia monitors require a reliable R-wave detector. QRS

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detectors rely on distinct characteristics of the QRS complex (e.g. amp, slope)

"" Morphology Characterization - group QRS

complexes base on their shape (10-20 groups/
clusters)

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Timing Classification - grouping QRS complexes based on timing of the complex -
the observed RR interval is compare to an estimate of the expected RR interval.

↳
- “Premature” if < 85% of the expected RR

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- “Long” if > 110% of the expected RR

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Beat labeling - normal, supraventricular premature beat, PVC, etc (VERY complex
algorithms, often kept secret by the companies who make them)

Rhythm labeling - detecting and identifying rhythms such as atrial fibrillation or

ventricular fibrillation

Atrial fibrillation detection - detection of a or all rhythms from the timing of the
QRS complex

Ventricular fibrillation - frequency domain detection ( Fft)

Summary stats, alarm - cardiac rhythms over long periods of time - tables, graphs
2-7 QRS detection techniques
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(Template matching)

HP: ST/AR arrhythmia algorithm

This is a multi-lead ECG algorithm for detecting arrhythmia and ST segment
monitoring. us

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Detection threshold is kept at 0.15 mV to prevent identifying T waves or
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Weight different ECG signals based on their quality, and then produce a QRS
detection signal:

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GENERATION

:*. Good signal = high weight

Bad/noisy signal = low weight
 After detecting the R-wave, ST/AR looks backwards at every ECG signal to
( determine if there was a P wave. It searches in a 200 ms area that ends 12 ms
before the R wave. =

In order to accept as a P wave, it must be at least 1/32 of the R wave height

AND the PR interval must be close to the expected PR interval

P-wave detection is used to differentiate between a sinus rhythm and a

supraventricular (SV) rhythm.

After detecting R wave, the QRS complex is label:

- normal (N)
- supraventricular premature (S)
- ventricular ectopic (V)
- paced (P)
- questionable (?)
- learning (L)
Part 4: Feb 1
Data Compression & Ambulatory ECG Monitoring

REDUCE # of BITS
Data Compression
(Size reduction) I
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STORAGE DATA TRANSFER
*LESS SPACE (REDUCED )
BIT RATE
REQUIRED )

} METHODS FOR ECG COMPRESSION :

TIME DOMAIN : REMOVE REDUNDANT (REPEATING IUNNECESSARY)

INFORMATION
- Scanning polygonal approximation
- amplitude zone time epoch coding
- Transformation domain:
- Fourier
- direct cosine transform
- wavelet transform
- wavelet/direct cosine combination
- Parameter extraction: some features of the ECG signal are first
extracted and then compression is applied

AZTEC data compression:

Data reduction rate = 10:1
QRS

Converts ECG signal into a series of straight lines: 1

- when signal is rapidly changing, AZTEC requires shorter line segments

eTWEEN
- when signal is slowly changing, AZTEC uses longer segment

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2 types of lines:
- straight line segments: voltage and time duration
- slopes: voltage variation (+/-) and time duration
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 Ambulatory ECG Monitoring

PORTABLE I
Goal of ambulatory monitoring: to record one or more physiological variables
continuously or repeatedly, without interference with the spontaneous activities
of the subject by the restraints of conventional laboratory instrumentation and
without influencing the variable(s) being measured.
Types of ambulatory ECG monitoring:

(1) Holter Monitor

- 24-72 hours of ECG waveform
- small recorder (70 x 95 x 20 mm, 200 g)
- use flash card memory
(2) Event Recorder
- limited monitoring during a specific cardiac event
- patient presses a button to start recording
- Example: ST analysis
- small systems, allow monitoring for longer periods of time
(3) real-time continuous cardiac monitoring systems
- worn continually
- automatically record and transmit (during arrhythmic events) to some
monitoring station
- 3 chest electrodes
- portable monitor (e.g. cell phone)
(4) implantable loop recorder
- subcutaneously implanted
- leadless
- signal: single lead ECG signal through 2 electrodes built into the system
- transmit continuously
- battery: 2 years