Journal of Biomedical Informatics 113 (2021) 103648

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Journal of Biomedical Informatics

journal homepage: www.elsevier.com/locate/yjbin

Original research

An hybrid ECG-based deep network for the early identification of high-risk to

major cardiovascular events for hypertension patients
Giovanni Paragliola ∗, Antonio Coronato
National Research Council (CNR) - Institute for High-Performance Computing and Networking (ICAR), Naples, Italy

ARTICLE INFO ABSTRACT

Keywords: Background and Objective: As the population becomes older and more overweight, the number of potential
eHealth high-risk subjects with hypertension continues to increase. ICT technologies can provide valuable support
Deep learning for the early assessment of such cases since the practice of conducting medical examinations for the early
Time series classification
recognition of high-risk subjects affected by hypertension is quite difficult, time-consuming, and expensive.
Early hypertension identification
Methods: This paper presents a novel time series-based approach for the early identification of increases in
Signal processing
hypertension to discriminate between cardiovascular high-risk and low-risk hypertensive patients through the
analyses of electrocardiographic holter signals.
Results: The experimental results show that the proposed model achieves excellent results in terms of
classification accuracy compared with the state-of-the-art. In terms of performances, our model reaches an
average accuracy at 98%, Sensitivity and Specificity achieve both an average value at 97%.
Conclusion: The analysis of the whole time series shows promising results in terms of highlighting the tiny
differences between subjects affected by hypertension.

1. Introduction
It is approximated that the 33% of adult human has hypertension
and that one out of two of these persons are unknowing of this shape. It
is rational, therefore, to suppose that regular cardiac disease screening
examinations can make easier an early diagnosis and make smaller the
risk of additionally complications associated with cardiac disease, such
as hypertension [1].
Although screening examinations are a conditio sine qua non for
the early diagnosis of hypertension, we should bear in mind that the
diagnosis process is more complicated than it seems [1]. Screening
programs for hypertension certainly have benefits but also these may
have potential disadvantages (e.g., false positives, long Waiting Time for
medical appointments, anxiety, psychological impacts, and economic
costs) [2].
Diagnosing and the medical treatment of hypertension plays a sig-
nificant role in decreasing the risk of cardiovascular disease [3]. How-
ever, the early recognition of symptoms of high-risk subjects affected
by hypertension is quite difficult due to the fact that anomalies, which
may be assessed as indicators of the onset of possible problems, are of
various kinds and are not always easily quantifiable.
For example, Fig. 2 shows the extraction of the data used in this
paper concerning the recording of the heartbeat of two subjects affected
by hypertension, one labeled as a high-risk subject with an anomaly and
the other as a low-risk subject. The red circle shows a minor change in
the signals that may be associated with an anomaly.
However, those anomalies only become apparent when vital signals
are evaluated quantitatively using an analysis system. Therefore, the
attention in the development of ICT tools for the early diagnosis and
prognosis of cardiac disease has been increased.
The aim of these tools is to support cardiologists in diagnostic tasks,
reducing both the number of missed diagnoses and the time taken to
reach such decisions.
Examples of such tools are digital questionnaires [4], risk factor-
based studies [5] and biological parameter-based techniques [6], the
majority of which adopt machine learning approaches to extract useful
information from the data.
Those focused on biological parameters identify possible anomalies
by looking for specific patterns in consecutive portions (named win-
dows) of the patient’s physiological signals, Therefore, such techniques
are defined as a window-by-window analysis of signals.
Unfortunately, it may be difficult to design a machine learning
model able to identify anomalies in physiological signals due to both
unclear definition of such anomaly patterns and the engineering trade-
off regarding to the design of the windows.

∗ Corresponding author.
E-mail addresses: giovanni.paragliola@icar.cnr.it (G. Paragliola), antonio.coronato@icar.cnr.it (A. Coronato).

https://doi.org/10.1016/j.jbi.2020.103648
Received 9 July 2020; Received in revised form 27 October 2020; Accepted 27 November 2020
Available online 1 December 2020
1532-0464/© 2020 Elsevier Inc. This article is made available under the Elsevier license (http://www.elsevier.com/open-access/userlicense/1.0/).
G. Paragliola and A. Coronato
We here introduce a novel approach for the analysis and classifi-
cation of the entire physiological signal to address the design issues of
traditional window-based approaches.
In detail, in this paper we describe a novel time-series(TS)-based ap-
proach for the early identification of an increase in hypertension to dis-
criminate between cardiovascular high-risk and low-risk hypertensive
patients, where high-risk subjects are those patients who experienced
critical events (such as myocardial infarctions, strokes, syncopal events,
etc.). Moreover, we have designed a hybrid deep learning network
(HDN) as a combination of three different networks, a Long Term
Memory Signal (LTMS), a Convolution Neural Network (CNN) and a
Deep Neural Network (DNN).
The evaluation of prediction models requires large datasets. For
this reason, the database SHARE [7] was selected for our proposes.
The database was downloaded from the Physionet Repository [8].
It contains more than 130 ECG recordings with the clinical data of
hypertensive subjects monitored for at least 12 months.
Subjects who endured a vascular event (i.e., myocardial infarction)
were assumed as high-risk subjects, the others as low-risk subjects.
The experimental results show that the proposed model achieves
excellent results in terms of classification accuracy. In addition, high
sensitivity and specificity rates have been achieved in the automatic
identification of subjects experienced vascular events within one year
of an ECG recording
2. Related work
The aim of this section is to highlight the contribution of our
solution. First, we will present an overview of the state-of-the-art
approaches for the assessment of hypertension so as to show that
our approach is the first based on a TS classification of physiological
signals.
Secondly, we will present an overview of other deep-learning mod-
els for the classification of a TS with the aim of comparing them with
our model. The experimental results will show the better performance
of our model compared to the other approaches.
2.1. Classic hypertension assessment approaches
High blood pressure is mostly asymptomatic, in particular in the
early stages, causing to its labeling as a silent killer [9]. The asymp-
tomatic feature of hypertension requires routine blood pressure screen-
ing.
Ambulatory blood pressure monitoring (ABPM) is judged as a gold-
standard approach of hypertension diagnosis at the time when a indi-
vidual has been examined and realized to have high blood pressure.
The goal of ABPM is to discover the disease at its earliest and most
treatable stage.
ABPM typically require the use of portable, automated cuffs worn
continuously that evaluate the blood pressure every 15/30 min in the
course of the day and 15/60 min during the night [10].
Despite their suitability for diagnosis, ambulatory monitors may
have potential drawbacks, such as high treatment costs and a long
waiting time for a medical examination [10]. In addition, the wearing
of cuffs and similar tools may be uneasy during the daily life and sleep.
The estimation of key risk factors influencing hypertension is an-
other method adopted to support early diagnosis.
Machine learning-based approaches have been used for the analysis
of questionnaires or/and biological parameters in order to evaluate risk
factors. There are many studies that demonstrate this techniques such
as: [4,11,12].
Generally, the identification of risk factors depends on a considera-
tion of characteristics including gender, age, practice sports, body mass
index (BMI), food habits, smoking or alcohol usage (substance abuse)
and a family history of the illness. The aim of these methods is to define
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Journal of Biomedical Informatics 113 (2021) 103648
a patient’s profile, so supporting an earlier identification of higher-risk
subjects.
Assessing risk factors is considerably more complicated since risk
factors may differ significantly from one region to another [4].
Other approaches rely on the application of machine learning tech-
niques for the analysis of the dynamic behaviors of a vital sign TS.
In [13] the authors propose a mortality prediction model and estimated
mortality risks over time based on TS of blood pressure and heart rate.
In [7] the authors, evaluate linear and non-linear heart rate variability
(HRV) analysis methods and pattern recognition schemes from holter
recordings. A prediction of blood pressure variability from TS data from
blood pressure measurements home and data acquired via a medical
examination at a hospital has been proposed in [14].
In [15] the authors propose a Convolution-Neural-network-based
hypertensive prediction scheme using blood pressure data taken over
a period of time to predict hypertension.
In these approaches a group of temporal windows is obtained
from TS signals. The choice of the window’s size and the overlapping
between two continuous windows is a standard engineering trade-off
problem making the designing process complicated and time-
demanding.
Fig. 1 reports an overview of the strengths and weaknesses of all
the approaches.
In this paper, our aim is to highlight and demonstrate that our
solution is the only one that adopts a TS classification-based approach
for the assessment of an early increase in hypertension.
2.2. State-of-the-art in relation to TS classification models
Time Series Classification (TSC) is a commonly encountered chal-
lenge. Now-day, there are a few solutions that address this issue. In the
previous section, we have highlighted that the application of a time-
series classification approach for the assessment of hypertension disease
is an innovative technique in the assessment of hypertension diseases.
In this section, we present a few well-known models for TSC that we
have implemented in our experiments to assess the prediction success
of those models compared with our solution.
The results prove that our solution achieves better results in terms
of an early identification of an increase in hypertension in order to dis-
criminate between cardiovascular high-risk and low-risk hypertensive
patients.
Fully Convolutional Neural Networks (FCN) [16] are for the most part
convolutional networks (CNN) that do not include any local pooling
layers (PL); the size of a TS is maintained unaltered across the convo-
lutions. Furthermore, an important features of FCN is the replacement
of a final Fully Connected (FC) layer with a Global Average Pooling
(GAP) [17]
Residual Network (ResNet) is a network that counts 11 layers, the
first 9 layers of which are CN follow on a GAP layer that averages
output of the CN. The layers are grouped in logical units named
residual blocks (RB). Each block consists of three convolution layers
of which the output is summed to the following input block and then
supplied to the following layer. The network is defined as three residual
blocks whose output feeds a GAP layer where the last is a softmax
classifier [16].
Encoder is a hybrid deep CNN similar to FCN but with a significant
dissimilarity. An attention layer replaces the GAP layer [18]. In the
same way as in FCN, this network consists of three CL with slight
changes. The third convolutional layer supplied to an attention mech-
anism [19] which make it possible for the network to discover which
segments in the TS are significant for the classification.
Time Le-Net (t-LeNet) can be taken into account as a classic CNN
with two convolution layers follow on behind an FC that feeds a
softmax. It is possible distinguish two variances with FCNs: the first
concerns the use of an FC layer instead of the GAP, and the second
relates to the local max-pooling operations on the output of each
G. Paragliola and A. Coronato
Fig. 1. Summary of the state-of-the-art for the hypertension assessment and evaluation.
Fig. 2. Comparison between the holter recordings of a high-risk subject and a low-risk
subject [7].
CNN layer. Unlike ResNet and FCN, this approach pushing up the
amount of parameters needed to be trained during the learning process,
which is based also on the size of the input TS. The use of t-LeNet
network is restricted since the number and length of the chosen filters
increases [20].
Multi Channel Deep Convolutional Neural Network (MCDCNN) was
suggested for multivariate TS (MTS) datasets [21]. The architecture
consist of a CNN adapted for MTS where the convolutions operation
acts independently for each dimension of the time-series. Each dimen-
sion of the MTS feed two CL followed by a max pooling layer, after that
the output is flatted and then fed to an FC.
The Time-CNN network was designed by Zhao et al. [22]. It is possi-
ble highlight three changes in comparison with the others architectures.
(I) Time-CNN is the adoption of mean squared error (MSE) instead
of the categorical cross-entropy loss function. (II) the last layer is a FC
with a sigmoid . (III) A local max pooling layer is replaced a with local
average pooling operation.
All the presented architectures aim at classifying a TS. Each model
has its strengths points and the literature shows that each achieves
good results. However, our model includes a novel feature that makes
it different from the other architecture.
Our model is the only one that adopts a recurrent layer (the LSTM
Network) as the first layer of the whole network. The output of this
layers is fed to a chain of CNN layers whose output is fed to an FC.
The justification of this choice is related to the nature of the
input TS. An electrocardiographic Holter recording is a class of signals
where a sequence of measurements is collected by sampling the heart’s
activity over the time domain. These sequences may present a relevant
sequential correlation between consecutive samples which should be
take advantage to enhance the accuracy of our classifier [23].
All the proposed architectures adopt as first layers a CNN network
that applies the convolution operator to a group of samples as wide as
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Journal of Biomedical Informatics 113 (2021) 103648
the size of the CNN’s filters. However, the core idea of our work is to
evaluate a different way of analyzing the sequence of samples.
In our solution, we adopt the LSTM network that is naturally
designed to analyze sequences.
In detail, it processes a sequence of values one sample at a time,
preserving in its internal state a data representation that holds informa-
tion about the all past items of the sequence. As a result, each sample
(timestamp) in an input TS is projected into a higher dimensional space.
2.3. Contribution of our work
Following the presentation of the state-of-the-art approaches, it is
worth summarizing the contribution of our solution.
– The literature shows a few methods focused on the assessment of
hypertension, especially those related to the identification of the
disease in its early stages.
Moreover, a study of the literature highlights the lack of any
approaches based on the TCS of the vital signs of patients with
hypertension, and for this reason, in our paper we are proposing
a TSC-based solution for the early identification of subjects at a
high risk of hypertension
– We present a novel hybrid deep network model to address TCS
by incorporating within our network a component specifically
designed to address the analysis of the sequence of samples.
We have compared our model with the state-of-the-art of TS-
based approaches. The results show the goodness of our model
on account of its achievements of a better performance.
3. Methods
3.1. Data description
We have adopted a database containing 24 h electrocardiographic
(ECG) holter recordings of 139 hypertensive subjects (49 woman and
90 man, average age 72 ∓ 7 years).
The subjects were supervised for 12 months after the recordings to
take note of major cardiovascular events (i.e. fatal or non-fatal strokes).
In the 12-month follow-up after the recordings, 17 patients put
up with a recorded event (11 myocardial infarctions, 3 strokes and 3
syncopal events) and for this reason, those subjects were considered as
high-risk (HRP), while the remaining ones as low-risk subjects (LRP) [7].
Each recording is labeled in accordance with the patients it belongs
to, HRP for the high-risk subjects, and (LRP) for the low-risk subjects.
Fig. 3 shows an examples of extraction of data recorded from the
subjects.
Fig. 2 is an image provided by Melillo et al. [7] with the purpose
of highlighting as details as possible the tiny differences between the
ECG signals of the two classes of subjects.
The red circle shows a slight change in the signal which may be
interpreted as an anomaly in the recording.
G. Paragliola and A. Coronato Journal of Biomedical Informatics 113 (2021) 103648

Fig. 3. Example of one of the ECG waveforms stored in the dataset.

Fig. 3 shows the structures of the data used for the training. The
signal is a multivariate TS (MTS) where each second of the raw signal 𝑦 = 𝑀𝑎𝑥𝑃 𝑜𝑜𝑙𝑖𝑛𝑔(𝑦𝑐𝑜𝑛𝑣 )
models one time-point (or training example). Each time-point is a
where ⊗ is the convolutional operator, and MaxPooling is a
vector of tree spatio-temporal features where each feature is a different
sub-sample-based discretization operator.
TS of an electrocardiographic holter recording acquired using various
The extracted features have the shape of a vector with dimension-
techniques [7]
ality equal to the kernel filter of the second CNN block.
The CNN Layer produces a sequence of features-vectors which
3.2. Hybrid deep model
must be flattened in order to submit it to the deep layer.
This operation is in charge of the Flatten layer that transforms a
Fig. 4 describes an overview of the proposed hybrid network.
set of one-dimensional vectors of features into a single vector that
At the top level (i.e. the input layer), the model is fed with the input
can be fed into a fully connected network.
TS.
The output of the flatten layer is fed into the deep layer, which
The model is composed of three components.
transforms the flatten vector into a space that makes the output
– The recurrent layer aims to address the temporal correlations easier to classify.
between the time points of the TS. This logical layer is defined – The Deep Layer is composed of a four stacked Deep Neural Net-
as a Long Short-Term Memory network (LSTM). Its capabilities work (DNN). Each layer is defined as a fully-connected layer.
of modeling the correlations of a temporal sequence constitutes Each fully-connected layer has a number of neurons half than
the main reason why we adopted the LSTM networks in this the previous one, followed by a bath normalization (BN) and
work [24]. dropout layers. A rectified linear unit (ReLU) layer is adopted as
The LSTM is defined as a sequence of unit cells for the analyzing an activation function to prevent saturation of the gradient.
of a sequence of data 𝑥1 , … , 𝑥𝑡 with t ∈ 1, 𝑇 , with T the length of The normalization layer is applied to speed up the convergence
the sequence. The generic value 𝑥𝑖 at a time point i is processed speed and help improve the generalization and the dropout layers
by a unit cell. to enhance the generalization capability.
Each time point of both the input and output TS is still shaped as A basic fully-connected layer is formalized as
a vector of features, whose dimensionality changes according to
𝑦𝑓 𝑐 = 𝑊 ⋅ 𝑥 + 𝑏
the unit cell’s filter size.
The LSTM’s output having been characterized by considering the 𝑦𝑏𝑛 = 𝐵𝑁(𝑦𝑓 𝑐 )
features of the input data to be ordered by time. 𝑦 = 𝑅𝑒𝑙𝑈 (𝑦𝑏𝑛 )
The state of the generic units at time t can be expressed as:
Since the output of the network can be stated as a binary clas-
𝑦𝑡 = 𝜙(𝑊 ⋅ 𝑥𝑡 + 𝑈 ⋅ ℎ𝑡−1 + 𝑏) sification, we have decided to adopt a Sigmoid layer as the acti-
vation function [25,26] for the last layer of the Deep Layer for
where 𝜙 is the sigmoid function, and W , U , and b are the
the classification of the input as a high-risk subject or low-risk
parameters which need to be fitted during the training, ℎ𝑡−1 is
subject.
the state of the previous unit.
On the right side of Fig. 4, we have reported a table summarizing
The LSTM counts one layer with a dimensionality of the output
a few of the hyper-parameters that we have used for the training
space of each cell equal to 10 units. Each output of a cell is fed
of the model.
as the input to the convolutional layer.
A comprehensive analysis of the internal structure of all the layers
– The Convolutional layer is in charge of generating a reduced
is outside of the scope of this paper. For more details, the reader
representation of the input by extracting the more informative
can refer to Lipton [24], Orbach [27] and Goodfellow et al. [28].
features from the data input. The layer is defined as two stacked
blocks, each one composed of a convolutional network (C), and a
4. Results
max polling layer (P). The first one has a kernel size of 10 units
for both C and P while the second has 8 units
4.1. Training
A convolutional layer adopts filters that process local partitions
of the input within which the convolutional operator is applied.
In this section we introduce both the training dataset and the
These filters are duplicated alongside the whole input. A sub-
learning process of our model.
sampling step (pooling) performers a smaller resolution version
First, the training data is extracted from the dataset downloaded
of the output of the CL by filtering the maximum value from
from the Physionet repository.
different local regions.
The personal recordings are each of about 24 h in duration and
At the conclusion, the convolutional layer extracts the most rele-
contain three ECG signals, each sampled at 128 samples per second.
vant features from each second by the input TS.
A fragment of 5 min recorded during the daytime was randomly
Each block is formally expressed as:
selected without replication for each subject. From each second, one
𝑦𝑐𝑜𝑛𝑣 = 𝑊 ⊗ 𝑥 + 𝑏 point was randomly selected.

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G. Paragliola and A. Coronato
Fig. 4. Overview of the hybrid model and summary of the hyper-parameters.
Each fragment is a single sample of the training dataset. Moreover,
each sample was labeled with a tag High or Low based on the subject
from which it was selected 5.
The number of samples selected from each recording was different
between high-risk and low-risk subjects to guarantee a fair balancing
between the two classes.
From each low-risk recording we selected 40 samples. However,
from each high-risk recording we select 160 samples so that the training
dataset would be well balanced between the two classes. In conclusion.
the training set consisted of more than 7000 samples (a.k.a time series).
We repeated this process both for the training set and the test set.
We adopted a 10-fold-cross-validation loop that was performed for
the model optimization (i.e. a Tuning hyper-parameters optimization),
while a hold-out test set was used to obtain unbiased estimates of the
true classification performance
For the test set, we selected one sample from each low-risk recording
and three samples from each high-risk. Therefore, the test set consists
of 177 samples.
At the conclusion, we reach a training–testing ratio between the two
datasets at by 2.5%
4.2. Performance evaluation
It is worth recalling that the results demonstrate the goodness of our
model in classifying a TS as a high-risk subject or a low-level subject.
Our model exposes itself as a binary classification.
For the training stage, we randomly split the whole training dataset
by defining a training set as 90% of the original set whereas the
validation set was defined as 10%.
For the evaluation of our model, four metrics were used: precision,
recall, accuracy and F1-Score [29].
These measurements are defined as follows:
𝑇𝑃
𝑅𝑒𝑐𝑎𝑙𝑙 =
𝑇𝑃 + 𝐹𝑁
𝑇𝑃
𝑃 𝑟𝑒𝑐𝑖𝑠𝑖𝑜𝑛 =
𝑇𝑃 + 𝐹𝑃
𝑇𝑃 + 𝑇𝑁
𝐴𝑐𝑐𝑢𝑟𝑎𝑐𝑦 =
𝑇𝑃 + 𝑇𝑁 + 𝐹𝑃 + 𝐹𝑁
Journal of Biomedical Informatics 113 (2021) 103648
𝑃 𝑟𝑒𝑐𝑖𝑠𝑖𝑜𝑛 ∗ 𝑅𝑒𝑐𝑎𝑙𝑙
𝐹1 = 2 ∗ (4)
𝑃 𝑟𝑒𝑐𝑖𝑠𝑖𝑜𝑛 + 𝑅𝑒𝑐𝑎𝑙𝑙
where:
– TP: true positives (i.e. the number of high-risk subjects properly
identified)
– FN: false negatives (i.e. high-risk subjects wrongly identified as
low-risk subjects)
– TN: true negatives (i.e, low-risk subjects properly identified)
– FP: false positives (i.e. low-risk subjects wrongly identified as
high-risk subjects)
The AUC (Area under the ROC Curve) is the entire two-dimensional
area underneath the entire ROC curve.
For the comparative experiments we implemented all TSC architec-
tures presented in the related work based on the indications reported
in the respective papers.
The aim of this section is to compare the performance of our model
against the other models. The training and the test were set are the
same for all architectures.
In order to achieve the best performance we searched for the best
configuration of our network by tuning the hyper-parameters of the
networks.
The tuning of our model was evaluated with a grid-search approach
with a view to setting the parameters at:
– Neurons per layers:{512; 1024; 2048; 4096}
– Learning rate: {0.01; 0.05; 0.001; 0.005; 0.0001}
– Epochs: {1000; 1500; 2000, 2500}
– Convolutional kernel size: {5, 10, 15}
– Pooling filter size: {5, 10, 15}
A grid search approach consist of an very thorough searching across a
given subset of the hyper-parameter space.
Fig. 6 shows the classification results. For each architecture we
(1)
report the best results and the worse and the average. The best results
refer to tests case in which the training stage had set with 2500 epochs
(2)
while the worst ones with 1000 epochs. The AVG column describes the
(3) average of all the test cases performed.
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G. Paragliola and A. Coronato
Fig. 5. Extraction of the training sample from the dataset.
Fig. 6. Overview of the performance results.
The first row reports the results of Melillo et al. [7] authors. The
authors adopt a non-TSC approach but we included them anyway
because they created the dataset and performed the first experiments
so defining a baseline for our work. There is no value of the F1-score
because the authors did not evaluate it.
Considering the best case, the results show that our model surpasses
all the other solutions by reaching an accuracy of 98%. The average
improvement of accuracy is about 13% ranging from a minimum of
6.12% [22] to a maximum of 18.37% [20].
The goodness of the model is also confirmed by the values of recall
and precision, both about higher than 95%. The F1-score reaches 96%
so confirming a good behavior of the model with respect to the false
positives and false negatives.
Considering the worst test-case, the results are better with average
improvements of accuracy of 16%.
The following figures reefers to the results achieved in the best test
cases.
Fig. 7 shows the confusion matrix of each architecture.
Sub-figure A-7 reports the average classification results on the test
set. The model is able to discern between the two classes with a high
precision.
The test set consists of 156 samples. Our model identifies the low-
risk subject (the false cases) with an accuracy of 98% (120 out of 122),
and the high-risk subjects (the true cases) with an accuracy of 96% (53
samples out of 55).
Fig. 8 presents the ROC curve showing the performance of our
classification model.
The curves of all the solutions have a very similar trend. However,
our model shows a higher AUC compared to the other architectures.
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Journal of Biomedical Informatics 113 (2021) 103648
5. Discussions
We have compared our approach to other well-known architec-
tures in identification of high-risk individuals among a population of
hypertensive patients
The results show the goodness of our solution. However, an honest
discussion considering the strengths and weaknesses, is needed
Fig. 8 shows the ROC curve. Our model achieves the highest AUC
values, equals to 98%, higher than the one obtained by Zhao et al.
[22] (95%). The AUC of our solution is better by 3%, in addition to
an average improvement of 9.7%.
It is important to note that there is a cross point at the false-positive
rate (FPR), equals to 25%. After this point, our model performs better as
the FPR increases and consequently, the response in terms of Recall is
better. This demonstrates that our model is able to avoid false positives
(i.e. a high-risk subject would predict as a low-risk)
Before this point our solution shows very similar results to Zhao
et al. [22] and Zheng et al. [21] and the improvements are negligible.
Fig. 7 shows the confusion matrix of each architecture.
It is worth noting that our model achieves a good performance
as regards false positive. The matrix reports only 2 false positives
which produces an improvement of more than 200% compared with
the best result of the other architecture ([21] with 6 false positives).
The average number of false positive is around 9, and consequently,
our model shows better results.
Concerning the true negative our model achieves results close to the
other architectures so there is no a clear improvement.
Figs. 9b and 9a show the trends of the accuracy and loss function
of our model during the training.
G. Paragliola and A. Coronato
Fig. 7. Overview of the confusion matrix of each architecture.
Fig. 8. Overview of the ROC curves.
It is possible to observe that in both figures the curves of the
training set and validation set are very close to each other. This results
demonstrates that the models is less affected by over-fitting issues.
At the beginning of the training process, the learning process shows
a fluctuating trend that gets smoother after the 250 epoch.
Figs. 10b and 10a show the trends the accuracy and loss function
of our solution compared with the other architectures.
The figures demonstrate that our model converges more slowly than
the others. This finding shows that our model reaches a local minimum
more slowly since it requires more epochs.
After 100 epochs the value of loss of our model is greater than
the majority of the other models: +99% (MCDCNN), +76% (Encoder),
+48% (FCN), +45% (LeNet), +43% (ResNet) and -82% (TCNN).
Every models reaches a stable point after 250 epochs but even at this
step our model does not show the best loss. At the last epoch the gap-
loss is +90% (MCDCNN), +73% (TCNN), 36% (Encoder), 5% (FCN),
−0.08% (LeNet), -4% (ResNet).
The slow convergence of our model is rewarded with a better
accuracy. Fig. 10b shows that at the end of the training the accu-
racy achieved by our model is the best. As regards the improve-
ment in the classification accuracy, our solution is better by: +5%
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Journal of Biomedical Informatics 113 (2021) 103648
(TCNN), +1.7% (Encoder), +2.9%(FCN), +7%(LeNet), +4% (ResNet)
and +1.6%(MCDCNN).
Fig. 11 show an overview of the training time duration of each
network. The column Trainable Parameters reports the number of inside
parameters of each network which have been fitted during the training.
Our model is the biggest network with more the 1.2 million parameters,
and consequently it takes the longest training time.
These results show that our model is able to achieve the best
performance in terms of discerning between high-risk subjects and low-
risk subjects. However, it shows a slow trending during the training.
This aspect increases the total amount of time needed by our model
to reach a local minimum point while the other solutions reach a
sub-optimal point faster.
From the experiments, we have learnt a some points which will
examine in depth in future activities, including:
– reducing the numbers of parameters. The high number of param-
eters makes the training process very long. This is the main issue
in relation of our approach which we are planning to investigate
in our future work. A Possible solutions cloud include changing
the network’s structure by modifying the layers.
G. Paragliola and A. Coronato Journal of Biomedical Informatics 113 (2021) 103648

Fig. 9. Trend of the loss and accuracy of the model compared with the validation set.

Fig. 10. Comparison of the trends of the loss and accuracy of all architectures.

8
G. Paragliola and A. Coronato
Fig. 11. Overview of the training time duration of each network.
– Increasing the dataset size: The dataset used for the training is a
good starting point. However, we are planning to test our model
with other bigger datasets which describe the same class of data.
The increasing of the dataset and the validation on a bigger
dataset will improve the goodness of our model and prevent it
from overfitting issues.
– Generalize the model: One of the future investigations will focus
on the application of the proposed model for different use cases
in order to make it as more generalizable as possible.
6. Conclusions
In this work we have presented a TS-based approach for the early
identification of high-risk subjects affected by hypertension.
Among other approaches for the assessment of hypertension, our
approach is the first one that adopts a TSC to differentiate between
high-risk and low-risk subjects.
We have compared our model with other deep network architec-
tures for the classification of TS and the results experiment shows that
our model achieves better results in terms of classification accuracy.
However, the high number of parameters of our model mean that it
takes a long time to complete the training.
The analysis of the whole TS shows promising results in terms of
highlighting the tiny differences between subjects affected by hyper-
tension.
CRediT authorship contribution statement
Giovanni Paragliola: Methodology, Supervision, Investigation,
Writing - review & editing, Visualization, Software, Formal analy-
sis, Writing - original draft. Antonio Coronato: Project administra-
tion, Funding acquisition, Resources, Writing - review & editing, Data
curation, Visualization, Formal analysis, Conceptualization.
Declaration of competing interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared to
influence the work reported in this paper.
Acknowledgments
This work is supported by the AMICO project which has received
funding from the National Programs (PON) of the Italian Ministry
of Education, Universities and Research (MIUR): code ARS0100900
(Decree n.1989, 26 July 2018).
We would like thank to Dott. Giovanni Donnici who is a cardiologist
at Dipartimento di alta specialità del cuore, AOR San Carlo di Potenza,
Italy for his contribution to the revision of the paper.
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Journal of Biomedical Informatics 113 (2021) 103648
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