art ic l e i nf o
a b s t r a c t
Article history:
Received 29 January 2016
Received in revised form
26 June 2016
Accepted 28 June 2016
In this study, the heart rate variability (HRV) analysis is used to distinguish patients with systolic congestive heart failure (CHF) from patients with diastolic CHF. In the analysis performed, the best accuracy
performances of short-term HRV measures are compared. These measures are calculated in four different
ways with optional normalization methods of heart rate and data. The nearest neighbor and the multilayer perceptron (MLP) are used to evaluate the performances in discriminating these two groups. The
results point out that using both data and heart rate normalizations enhances the classier performance.
The maximum accuracy is obtained as 96.43% with MLP classier.
& 2016 Elsevier Ltd. All rights reserved.
Keywords:
Heart rate variability
Heart failure
Normalization
Multi-layer perceptron
Nearest neighbor
1. Introduction
When the pumping capacity of a heart reduces, this disorder is
called heart failure. As the accumulation of blood is so common in
patients with heart failure, it is also named congestive heart failure
(CHF). The failing heart does not manage either to pump or to ll
up, which are called systolic heart failure and diastolic heart failure, respectively [1]. Although the most essential element for the
success of the treatment is the reliable and exact diagnosis of CHF,
systolic dysfunction was determined in only half of all cases and
only 46% of physicians tried routinely distinguishing either systolic
or diastolic dysfunctionality in the patients with CHF [2]. The decreased pump function (i.e. systolic CHF) can be measured by
functional cardiac studies (e.g. ECG, BNP, and echocardiogram) [3
5]. On the other hand, the diastolic dysfunction is identiable by
only echocardiogram [6,7].
Almost 90% of physicians routinely performed ECG tests in
patients due to its simplicity [2]. Nonetheless, physicians accepted
that echocardiography is essential in diagnosis whether patient
with CHF is systolic or diastolic in addition to clinical sign and
symptoms [8]. Average waiting time for echocardiography was
1 month and that was 48 h for ECG [2]. Hence, simple and reliable
diagnostic procedures based on ECG may be helpful for primary
care physicians (PCPs) who are responsible for the early diagnosis
of CHF and implementation of adequate therapy.
Analysis of heart rate variability (HRV), derived from the ECG
E-mail address: islerya@yahoo.com
http://dx.doi.org/10.1016/j.compbiomed.2016.06.029
0010-4825/& 2016 Elsevier Ltd. All rights reserved.
114
2. Methods
2.1. Experimental protocol
Patients came to the clinics after their breakfast at the morning,
which took approximately 2 h from their home to clinics because
of the morning trafc in Izmir, Turkey. Patients were requested to
rest at least 10 min just before connecting Holter device. After the
connection, patients waited for 10 min in resting position on a
comfortable chair. During this time, the required paper work was
also completed. Then, they left the clinics and continued their
daily life. They came back to the clinics again approximately 24 h
later. 30 patients from all patients were included into the study
after two experts analyzed the data.
The collected data were digitized at 128 samples per second.
There were 115,200 peaks in ECG by supposing 80 beats per
minute during 24 h for each patient. Ectopic beats are excluded
from HRV analysis in general [9]. Deciding such a big amount of
beats whether normal or ectopic is very time-consuming and irritable process for experts. Moreover, this process is costly for
health industry. That is the reason why the rst 5-min segments of
all recorded ECG data are included in this study. In addition, using
only 5-min (300-s) sections of data helps us achieving the discrimination faster and not disturbing the patients longer in a clinic
environment.
2.2. Data
The Holter ECG data used in this study were obtained from the
Faculty of Medicine in Dokuz Eyll University [24]. Two cardiologists decided whether patients would be included into the study
or not. The data included the study are as follows:
Age of the patient, time-domain, frequency-domain and non-linear methods are used in HRV studies. For further details, the studies given in the references could be examined [19,24,20].
Welch periodogram method, which uses fast Fourier transform
(FFT) method, is commonly used for the evaluation of frequency
domain [25]. Thanks to this method, power spectrum density
(PSD) over the data that is sampled at equal interval through the
time can be computed. In this study, HRV data is re-sampled by
using cubic interpolation method at 4 Hz before using FFT and
detrending of data is eliminated for providing stability analysis
[25]. Besides, evaluation of frequency domain obtained by Lomb
periodogram which is developed as an alternative to the classical
PSD method is also used. Owing to this method, PSD can be
computed from directly the HRV data without needing to resample on time domain [2628]. HRV evaluation of conventional
frequency domain for 5-min period is examined in detail by the
recommended standard [9].
There are three frequency bands commonly used in HRV analysis: VLF (00.033 Hz), LF (0.0330.15 Hz) and HF (0.150.4 Hz) [9].
In the evaluation of frequency domain, powers of these frequency
bands from calculated PSD were examined. Therefore, the following frequency domain measures were computed separately for
both methods of Welch periodogram and Lomb periodogram. The
frequency domain analysis contributed to the understanding of
autonomic background of RR interval uctuations in the HR record
[42,43].
On the other hand, wavelet analysis not only makes possible
the examination of one signal for the both time and scale domains
but also eliminates polynomial non-stability [29]. Wavelets are
reported as very useful for analysis of the RR intervals due to this
capability. Thus, Daubechies-4 main wavelet over HRV data resampled at 4 Hz with the 7-level wavelet transform method was
also used in this analysis to calculate the standard frequency domain features of HRV analysis [19].
Furthermore, non-linear measures derived from Poincare map
were used in this study. Poincare plot is a graph that each RR interval is plotted against the previous interval, which visualizes
detailed beating pattern of the heart. The Poincare plot is a popular technique thanks to its simplicity and its proved clinical
ability. Fitting an ellipse to the Poincare plot's shape and calculating measures from the plot is the most popular method among
nonlinear interpretation methods of HRV [3033].
As a result, 29 features were used. Those are obtained from
patient information, time domain evaluation, frequency spectrum
evaluation and non-linear methods with the numbers of 1, 6, 18,
and 4, respectively.
2.4. Normalization
Systolic CHF data: 18 patients (11 men and 7 women) with the
Diastolic CHF data: 12 patients (4 women and 8 unknown) with
HRN =
60
HRV
NewHR
HRV
(1)
fi, N =
fi min(fi )
max(fi ) min(fi )
(2)
115
ACC =
TP + TN
TP + TN + FP + FN
(6)
SEN =
TP
TP + FN
(7)
SPE =
TN
TN + FP
(8)
dist (j, k ) =
|fi j
fik |2
(3)
i=1
j
yi = f wjixi
i=1
E=
1
2
(4)
( di yi )
i
(5)
116
Fig. 1. Flowchart of the system with optional heart rate and data normalization processes. The dashed lines show the optional steps.
3. Results
All the features extracted from the HRV data and the HRN data
are given in Table 1. Statistical signicances (p-values) of HRN
measures are better than those of HRV measures in time-domain
and nonlinear parameters in general.
Statistical signicances (p-values) of measures are summarized
in Table 2 to show the effect of optional data normalization step.
After applying the HRN-based data normalization method, average
statistical signicance values are drastically reduced.
The application is run for eight different congurations:
with NN and MLP classiers. The performances of all the congurations are calculated based on their accuracy measures (see
Tables 3 and 4). The results show that using both MINMAX and
heart rate normalization procedures improve the performance of
the classication processes. The maximum accuracy is found to be
96.43% in the conguration of MINMAX and heart rate normalized
117
Table 1
Standard short-term HRV indices: patient information, time-domain, frequency-domain (estimated from periodogram techniques using both FFT and LS algorithms in
addition to wavelet entropy measures), and Poincare plots.
Feature
HRV
HRN
Systolic CHF
Diastolic CHF
Systolic CHF
Diastolic CHF
0.9727 0.38
1.521 7 1.79
1.698 7 2.16
1.0007 2.00
0.006 7 0.01
1.7317 2.13
0.542
0.313
0.379
0.349
0.349
0.360
0.800 7
0.282 7
0.3347
0.0007
0.0007
0.325 7
0.800 7
0.8917
0.996 7
0.250 7
0.0017
1.0097
1.000
0.214
0.257
0.150
0.150
0.236
115.82 7 224.39
4.337 5.30
19.893 7 36.06
0.1807 0.26
0.598 7 0.41
0.402 7 0.41
0.187
0.468
0.705
0.559
0.424
0.414
9.317 14.79
84.658 7 239.45
19.0457 53.87
0.427 7 1.21
0.734 7 0.22
0.2667 0.22
115.82 7 224.39
1.602 7 1.87
10.363 7 19.72
0.059 7 0.07
0.598 7 0.41
0.402 7 0.41
0.187
0.468
0.705
0.559
0.424
0.414
0.454 7 0.14
0.220 7 0.19
0.073 7 0.04
0.1737 0.09
0.308 7 0.06
0.692 7 0.06
0.159
0.872
0.075
0.402
0.028
0.028
2.7157
0.229 7
0.1907
0.129 7
0.599 7
0.4017
0.454 7 0.14
0.220 7 0.19
0.0737 0.04
0.1737 0.09
0.308 7 0.06
0.692 7 0.06
0.159
0.872
0.075
0.402
0.028
0.028
0.315
0.101
0.366
0.039
0.518
0.507
1.0717 0.61
0.390 7 0.49
1.0317 0.87
0.8477 0.49
0.4827 0.14
0.5187 0.14
1.8077
1.034 7
0.583 7
0.265 7
0.543 7
0.4577
1.90
0.77
0.72
0.13
0.20
0.20
0.315
0.101
0.366
0.039
0.518
0.507
0.348
0.300
0.405
0.448
0.225 7
0.3067
0.398 7
0.581 7
0.7167
1.006 7
1.503 7
0.740 7
0.85
1.26
2.09
0.08
0.236
0.216
0.226
0.444
Time-domain measures
MEAN
0.874 7
SDNN
0.542 7
RMSSD
0.6827
NN20
0.250 7
PNN20
0.0027
SDSD
0.6787
0.34
1.38
1.73
0.71
0.00
1.85
1.26
1.44
5.16
0.38
1.2247
1.7327
4.859 7
0.7327
1.56
2.34
7.85
0.08
Table 2
Average statistical signicances of both HRV and HRN measures.
HRV
HRN
Time-domain measures
Frequency-domain measures (FFT periodogram)
Frequency-domain measures (LombScargle)
Frequency-domain measures (wavelet entropy)
Nonlinear measures (Poincare plot)
0.3820
0.4595
0.2607
0.3077
0.3753
0.2014
0.4595
0.2607
0.3077
0.2805
Mean values
0.3570
0.301
Feature set
Table 3
Classier results of the nearest neighbor classier, SEN is sensitivity (%), SPE is
specicity (%), and ACC is accuracy (%).
HRV
HRN
Before MINMAX
2.97
0.19
0.12
0.08
0.22
0.22
0.52
0.67
1.06
0.32
0.00
1.02
1.18
0.50
0.00
1.19
Table 4
Classier results of the MLP classier, SEN is sensitivity (%), SPE is specicity (%),
and ACC is accuracy (%).
Method
Feature set
0.00
0.62
0.76
0.00
0.00
0.76
After MINMAX
SEN
SPE
ACC
SEN
SPE
ACC
62.50
68.75
75.00
83.33
67.86
75.00
87.50
87.50
83.33
91.67
85.71
89.29
HRV
HRN
Before MINMAX
After MINMAX
SEN
SPE
ACC
SEN
SPE
ACC
68.75
75.00
83.33
91.67
75.00
82.14
81.25
93.75
91.67
100.00
85.71
96.43
118
Conict of interest
None declared.
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Yalcin Isler (1971) received the B.Sc. degree in Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree in
Electronics and Communication Engineering, Suleyman Demirel University, Isparta,
Turkey, in 1996, and the Ph.D. degree in Electrical and Electronics Engineering,
Dokuz Eylul University, Izmir, Turkey, in 2009.
He worked as a lecturer in Burdur Vocational School of Suleyman Demirel
University (Burdur, 19932000), as a software engineer at the Department of
Research and Development in commercial companies (Izmir, 20002002), as a
research assistant in Bulent Ecevit University (Zonguldak, 20022003) and in
119