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Article history:
Received 15 April 2014
Accepted 12 August 2014
To diagnose health status of the heart, heart monitoring systems use heart signals produced during each
cardiac cycle. Many types of signals are acquired to analyze heart functionality and hence several heart
monitoring systems such as phonocardiography, electrocardiography, photoplethysmography and
seismocardiography are used in practice. Recently, focus on the at-home monitoring of the heart is
increasing for long term monitoring, which minimizes risks associated with the patients diagnosed with
cardiovascular diseases. It leads to increasing research interest in portable systems having features such
as signal transmission capability, unobtrusiveness, and low power consumption. In this paper we intend
to provide a detailed review of recent advancements of such heart monitoring systems. We introduce the
heart monitoring system in ve modules: (1) body sensors, (2) signal conditioning, (3) analog to digital
converter (ADC) and compression, (4) wireless transmission, and (5) analysis and classication. In each
module, we provide a brief introduction about the function of the module, recent developments, and
their limitation and challenges.
& 2014 Elsevier Ltd. All rights reserved.
Keywords:
Heart monitoring system
Cardiovascular diseases
Cardiography
Electrocardiography
Phonocardiography
Photoplethysmography
Seismocardiography
1. Introduction
Worldwide, the number of patients of cardiovascular diseases
(CVD) is huge [1]. Mortality caused by CVD in 2008 was 17.3
million which represents 30% of global deaths. In the U.S. alone,
2200 persons lose their life due to CVD each day [2]. According to
American Heart Association (AHA) report, the total cost of CVD
and stroke in the U.S. for 2008 is estimated to be 298 billion dollar
[1]. 80% of the total mortality caused by CVD occur in low and
middle-income countries.
These gures indicate need of systems that should be (1) sensitive to detect CVD at early stage, (2) capable of continuous
monitoring, (3) light weight for portability, (4) cost effective. Lack
of early stage detection and hence delay in medication causes
heart diseases to extent at a level where it is difcult to cure [3].
Persons diagnosed with CVD need continuous monitoring of
health status of their heart as they are at a higher risk to their
lives as compared to the normal persons. According to the Heart
Association, people diagnosed with CVD have 46 times higher
mortality than normal one [4]. Portability of such systems makes it
highly useful for elderly patients as this minimizes visits to clinics
or hospitals. A cost effective system will emphasis the use of heart
monitoring systems in low and middle income countries. Proper
http://dx.doi.org/10.1016/j.compbiomed.2014.08.014
0010-4825/& 2014 Elsevier Ltd. All rights reserved.
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
Initial electrocardiography (ECG) was based on string galvanometer and was invented by Willem Einthoven in 1903. As
discussed in Section 2, an electrical impulse originates at sinoatrial
node and then travels through atria and ventricles. ECG measures
the electrical activity of heart using electrodes placed on both side
of the heart. The measured signal consists of different waves
named as P, Q, R, S, T and U as shown in Fig. 4(a). P wave
represents atria contraction while Q, R and S waves (called as QRS
complex) reect contraction of both left and right ventricles. T
wave represents relaxation of ventricles and U wave is caused by
the relaxation of inter-ventricular septum. Thus duration and
amplitude of these waves provide signicant information for
diagnosis of health status of heart.
Extraction of duration and amplitude of some of the waves (P, T
and U) is difcult due to very weak amplitude, typically in the
range of 100300 V [14]. ECG signal lies in frequency band of 1
250 Hz, where icker noise is dominant and common-mode
interference from the main power line is likely to interfere with
4. Body sensors
Different body sensors acquire heart signals in different forms
such as electrical signal, acoustic signal, seismic signal, and optical
Fig. 4. Signals of one cardiac cycle: (a) electrocardiography signal, (b) phonocardiography signal, (c) seismocardiography signal, and (d) photoplethysmography signal.
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
0 A
d
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
Table 1
Three types of electrodes.
Characteristics
Wet electrodes
Dry electrodes
Capacitive electrodes
Signal acquisition
Signal quality
Size
Noise vulnerable
Movement artifact
cost
Lower cost
Expensive
Consistency
Convenience
5. Signal conditioning
Heart signals, acquired by different body sensors, often get
contaminated by noise components such as icker noise,
common-mode interference, power-line interference, and baseline
wandering [15]. Also, amplitude of the acquired signal is typically
low. A signal conditioning module typically consists of algorithm
for noise minimization and amplier to amplify low amplitude
signals. This module operates on signals in analog domain. Power
consumption of this module used to be low so as to support long
term operability of heart monitoring systems. For the same
purpose, Rieger [30] proposed a variable gain circuit consisting
of a continuous-time input stage using lateral bipolar transistors.
Spinelli et al. [31] proposed a driven right leg circuit to reduce
common-mode interference. Gomez-Clapers and Casanella [18]
used dual ground conguration to reduce the noise caused by
power line interference and base line wandering. Since most of the
heart monitoring systems are digital in nature and need communication for remote monitoring, the following section discuses
about analog to digital conversation (ADC) and compression
algorithms.
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
b
subject to Y X
Table 2
Digital signal processors.
Processor
No. of bits
Power consumption
Used in
Characteristics
PIC24FJ64GA
10
32
[6]
PIC18f2423
12
40
[33]
PIC16F877
20
[34]
MSP430f2274
10
16
[18,35]
Ultra-fast wake-up
Ultra-low power
RISC mixed-signal microprocessors
MSP430F1611
12
[36]
MSP430F2410
12
16
[37]
Ultra-fast wake-up
Ultra-low power
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
7. Wireless module
Digitized and compressed heart signals are transmitted to
remote site. In off-site monitoring, analysis and classication of
the heart signals are performed at the remote site. Transmitter
consists of wireless module which helps to transmit heart signals
to remote site. Low power consumption, convenient connection
process, and low latency are some important features of wireless
modules that promote wide acceptance of heart monitoring
systems. In the literature, various wireless communication techniques and protocols have been proposed for transmission purpose (Table 3). Bluetooth 4.0 [37] wireless system supports
24 Mbps data rate, has working range up to 100 m, and consumes
low power. Bluetooth devices with these features are suitable to be
integrated with heart monitoring systems. But Bluetooth wireless
systems require initial connection setup that has to be done
manually. Patient's intervention is not desirable in a heart monitoring system as it reduces convenience. To overcome this
problem an approach was proposed by Morak et al. [37] using
radio-frequency identication (RFID) and near eld communication (NFC). In this approach, the connection establishes by bringing two NFC enabled devices closer and using RFID information of
both devices. The drawback of this approach is that it requires
permanent activation of Bluetooth which results in extra power
consumption. Moreover, NFC can support data rate up to 424 kbps
only. Since data rate is lower than Bluetooth 4.0, it takes long time
to transmit data. A good review of the state-of-the art technologies
for wireless network was presented by [32].
Keeping in view the desired features of wireless module,
various protocols have been proposed [6,36]. Chen et al. [36]
proposed a reliable protocol based on any-cast routing algorithm.
This algorithm automatically selects nearest hop (sink), in case of
failure in original path, instead of rebuilding the path from the
source node. Thus, it provides a reliable communication as well as
reducing trafc overhead and transmission latency. However,
selection of the hop process increases the complexity of routing
algorithm and the complexity increases power consumption. To
optimize power consumption, Nemati et al. [6] proposed an ANT
protocol. The ANT protocol was used as a low-data-rate wireless
module to reduce the power consumption and size of the sensor.
ANT is an adaptive isochronous ad hoc wireless protocol based on
master slave model. It consumes from 1 mA to 6.3 mA current and
supports many topologies such as peer-to-peer, star, tree, and
mesh. SimpliciTI is also a low power radio frequency (RF) network
protocol used in heart monitoring systems [18,35]. SimpliciTI was
designed by Texas Instruments for easy implementation and
deployment on RF platforms. It is low data rate and low duty
cycle protocol and supports star and peer-to-peer network
topology.
Ma et al. [50] proposed an unequal-error protection approach
for heart signals to reduce transmission distortion and to reduce
power consumption of wireless transmission. In this approach
more protection is provided to the segment of heart signal which
contains diagnostic important features compared to the other
segments. Results showed that nearly 40% of transmission energy
can be saved compared to the equal error protection.
In a different approach, Atakan et al. [53] introduced the concept
of a body area network (BAN) with molecular communication,
where the messenger molecule is used as a communication carrier
Table 3
Wireless modules.
Module
CC2420 (zigbee)
Bluescense (blutooth)
nRF24E1 (Eco-wireless)
ANT-AP2
cc2500 (zigbee)
UZ2400 (zigbee)
Zebra (zigbee)
BlueNiceCom-4 (bluetooth class-2)
Xbee (Emosense)
Power consumption
Receive
Transmission
18.8
33
22
17
13.3
18
17.4
65
50
10
15
21.2
22
45
Size (mm)
Manufacturer
Used in
77
37 21
13 11
20 20
44
66
16 33
27 16
24 27
70
Texas instruments
Corscience
UC Irvine
Dynastream Innovations
Texas instruments
Uniband Electronics Corp.
senTec Elektronik
AMBER wireless
Digi International Inc.
[54]
[55]
[56]
[6]
[18,35]
[36]
[57]
[37]
[58]
10
30
30
10500
20
3090
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
8.2.1. Electrocardiography
ECG signal consists of different waves, as discussed in Section 4
(A). Each wave is associated with particular functionality of the
heart. Analysis of the shape of these waves leads to diagnosis of
important cardiovascular diseases which includes MI, hypertensive heart diseases, arrhythmia, CHD. The impact of CVDs can be
seen on the waves in ECG signal. Myocardial infarction causes ST
elevation or depression depending on the severity of the infarction. Location of the infarction can be identied by analyzing ECG
signals of different leads. In the case of hypertension, QRS voltage
increases due to both thickening of wall (pressure overload) and
dilatation of chamber (volume overload) of the left ventricle. The
RR interval is critical in the diagnosis of many arrhythmia such as
premature ventricular contractions, left and right bundled branch
blocks, and paced beats [70].
Classication of ECG signals is performed by analyzing shape of
the waves presents in the signal. Parameters of the shape of the
waves act as features for classication algorithms. Computational
requirement of classication algorithms depends directly on the
number of the features used and accuracy of classication depends
on quality of the features. Thus, feature selection plays a prominent role in the classication of ECG signals. In the literature, many
approaches have been proposed to select optimal features. Bashir
et al. [70] calculated QRS, P and T waves morphological parameters
as features to detect different arrhythmia. Then a parameter score
was calculated for an adaptive selection of feature subset for
particular arrhythmia. Accordingly, there will be a different feature
set for each arrhythmia, which enhances the accuracy, and at the
same time reduces the computational burden. While, Llamedo and
Martinez [71] calculated interval features and morphological
features for classication of arrhythmia. Interval features were
calculated from R peaks, and morphological features were calculated from three sources, RR interval, 2-D vectocardiogram loop
and DWT of the ECG signal. Then outliers form the feature set
were removed based on Kurtosis coefcients. Mar et al. [72]
applied sequential forward oating search algorithm with a new
criterion function index. Drawback of the proposed method is that
in many cases the subset with highest criterion value has a very
large number of features. Kamath [73] selected mean of Teager
energy operator (TEO) in the time domain and frequency domain
as features set. Key characteristic of the TEO is that it models
energy of the source that generated signal rather than the energy
of the signal itself. Hence, any deviations in the regular rhythmic
activity of the heart get reected in the TEO. Most of the above
algorithms face the same challenge, requirement of a large
number of the feature set. Large number of feature set is required
for diagnosis of the different types of diseases, but it results in
large computational complexity. Another challenge is due to
variation in morphological descriptors of the heart signal
with time.
Since mathematical operators work in the time domain, these
are computationally efcient and hence consume low power.
Mathematical morphological operators have been used [74] to
extract structural information of the ECG signals. However, computational requirement increases as increment in order of the
operators. To optimize computation requirement, Zhang and Bae
[8] proposed 1 dilation and 1 erosion based morphology operator
sets. However, effectiveness of these algorithms depends on the
selection of three structural components of the operator, shape,
length, and amplitude.
T wave delineation is crucial as prolongation of T wave to end
of the T wave is associated with ventricular pre-arrhythmicity and
sudden cardiac death. Noriega et al. [75] analyzed respiration
effect on T wave. Atrial brillation (AF) is associated with an
increased risk of cardiovascular and coronary artery disease,
hypertension, etc. AF is typically diagnosed by analyzing irregular
8.2.2. Phonocardiography
As discussed in Section 4.2, PCG signal consists of four sound
components. Characteristics (intensity, frequency, and duration) of
these sound components change due to the presence of CVDs.
Additional murmur sounds may also be present in PCG signal due
to the presence of CVDs. Although PCG can indicate abnormalities
caused by important CVDs, it is used extensively for diagnosis of
valvular diseases as sound components are produced by the
valvular activity [10]. Valvular diseases cause systolic and diastolic
murmurs. Aortic stenosis (AS), pulmonary stenosis (PS), and mitral
regurgitation (MR) cause systolic murmurs. On the other hand,
diastolic murmurs occur due to aortic regurgitation (AR), mitral
stenosis (MS) etc. Systolic murmurs, AS lies in the frequency band
of 120250 Hz, PS lies in 200250 Hz, and MR lies in 300400 Hz.
MR can be classied from other two systolic murmurs (PS and AS),
as with wider duration and higher frequency band. S1 also
becomes quieter than normal, in case of MR. Whereas PS causes
longer duration between aortic and pulmonary components of the
S2, called as split S2. Splitting of S2 also may occur due to atrial
septal defect and right bundle branch block. Diastolic murmurs lie
in 100250 Hz. MS causes mid-diastolic murmur with louder S1
and causes a high frequency opening snap of 90130 ms after the
aortic component of S2. While AR is relatively louder than other
diastolic murmurs. But more severe AR causes a lower intensity
murmur with longer duration. Two other sound components, S3
and S4, in PCG signal rarely occur and may indicate abnormalities.
Presence of S3 in a child is normal, while in adults, it represents
diastolic overload or cardiomyopathy [77]. S4 occurs just after
atrial contraction and it may be due to ventricular hypertrophy or
pulmonary arterial hypertension [77]. Analysis of the sound
components and the murmurs leads towards to the classication
of the PCG signals.
Heart sound classication algorithms rst partition the PCG
signal into S1, S2, systole, and diastole intervals, by emphasizing
them. To emphasize the heart signal components, envelop based
parameters such as Hilbert transform, Shannon energy, cardiac
sound characteristic waveform (CSCW) and timefrequency
domain analysis such as STFT and wavelet have been presented
in the literature. After segmentation of components, classication
of PCG signal is performed by analyzing the characteristics of these
components.
Envelope extraction based classication algorithms are able to
detect fundamental heart sound components and to classify the
signal as normal or abnormal. Choi and Jiang [78] compared three
envelope extraction algorithms, normalized average Shannon
energy; envelope information of Hilbert transform, and the CSCW.
As shown in the results, CSCW gives a more uniform representation of the fundamental components. The main challenge for the
envelope extraction based algorithm is the selection of the threshold value. A higher value of threshold missed the S1 and S2, while
the lower value of threshold detects spurious components and
inaccurate S1 and S2. To resolve this problem, Atbi et al. [79]
proposed a two step thresholding scheme. In the rst step threshold is selected to detect S1 and S2 and in the next step, to detect
murmurs. Envelop extraction based algorithms are computationally low complex. However, the performance of these algorithms
depends on the morphology of the PCG signal. Furthermore, it
becomes difcult to detect S1 and S2, where murmurs are merged
with them.
Frequency domain transformation techniques such as Fourier
transform, discrete cosine transform, and auto-regressive based
spectral analysis techniques provide frequency characteristics of
10
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
PCG signal components. However, timefrequency domain analysis is more suitable for PCG signal analysis due to the diagnostic
signicance of timing and frequency of PCG components. Time
frequency analysis of PCG signal has been done using short time
Fourier transform (STFT) [10,80], wavelet transform [80,81]. Boutana et al. [10] classied murmurs from PCG sound components by
analyzing the Renyi marginal entropy of STFT coefcients. Renyi
marginal entropy remains high for murmurs and low for sound
components. While, author [80] implement the PCG analysis
algorithm using STFT and wavelet on digital signal processing
board. In [81], rst heart sound signal is segmented into intervals
associated with cardiac cycle. Then intervals were grouped
together based on similarities between their STFT coefcients. In
STFT, a trade off between time resolution and frequency resolution
arises. Increment in size of time window increases the frequency
resolution, but reduces time resolution and vice versa. Thus,
selection of the optimal size of time window is crucial. For time
frequency analysis, wavelet offers a better compromise in terms of
resolution. Its main difference with STFT is that the size of the
window is not constant. It varies in inverse proportion to
frequency in such a way that good time and poor frequency
resolution obtain at high frequencies while good frequency and
poor time resolution obtain at low frequencies.
PCG signals have been classied using articial intelligence
algorithms such as Hidden Markov model [9] and neural network
[82,83]. Extracted features from PCG signals using time and
frequency analysis tools such as wavelet are used as feature points
for these articial intelligence techniques [82,83]. Use of the
machine learning algorithms reduce tedious envelop analysis
and its disadvantage in case of murmurs can be avoided, but at
the cost of having to prepare the training dataset. To prepare the
training dataset for PCG signal, Ahlstrom et al. [84] proposed a
feature subset selection algorithm from features of different
domain, including Shannon energy, wavelet, fractal dimension,
and recurrent quantication analysis.
PCG signal modelling is required to generate test data to
analyze efcacy of the developed algorithm. Modelling of PCG
signals has been done using exponential damped sinusoidal model
[85], matching pursuit method [86]. These methods provide
complete parameterization of the signal, but require a large
number of components. Whereas linear chirp signal modelling is
not suitable for PCG signal because components of PCG signal do
not have a linear relationship with time. To achieve better
accuracy, Xu et al. [87] proposed non-linear chirp signal modelling
of the heart sound components.
8.2.3. Seismocardiography
Seismocardiography (SCG) measures mechanical vibrations
produced by heart during each cardiac cycle. As discussed in
Section 4.3, SCG signal is composed of many waves. Each wave is
associated with a particular event of the cardiac cycle. Thus,
analysis of these waves provides diagnostic information related
to the health of the heart. In [88], author studied the relation
between the cardiac event position in SCG with ultrasound signal
and showed SCG as an accurate indicator for cardiac events. Thus
SCG signal can be used to detect cardiac cycle boundary, heart rate
[89], heart rate variability [90]. SCG signals have been also used to
obtain systolic blood pressure (SBP) [24]. It was shown that SBP
has the correlation with starting point of the SCG signal in the
x-axis to the midpoint of the z-axis. However, SCG has been used
for the heart monitoring purpose, but its sensitivity to motion
noise imposes limitation on its wide use.
Characterization of the relation between SCG signal and ECG
signal provides signicant information related to heart functionality. Wick et al. [88] analyzed relation between the R wave of ECG
and the AC wave of SCG signal. The R-AC period varies across two
individual and also for the same person at different heart rates.
This study strongly suggested the cardiac events also vary in the
same manner. Tavakolian et al. [91] analyzed period between the R
wave of the ECG and the AO wave of SCG to analyze the myocardial
contractility. This period is called as pre-ejection period (PEP),
increment in the PEP indicates reduction in contract-ability of
myocardial. Moreover, SCG has potential benets over ECG such as
better specicity and sensitivity for detection of coronary artery
diseases [92].
8.2.4. Photoplethysmography
PPG signal contains sufcient parameters to measure heart
rate, arterial oxygen saturation, and information related to
respiratory system [27,93,94]. As discussed in Section 4.4, PPG
measures variation in intensity of light, reected or transmitted,
induced by variation in the amount of blood in blood vessels.
Respiration information can be extracted using three vital
parameters: PPG amplitude, variation in SpO2, and respiratory
sinus arrhythmia [27]. Now a day, pulse oximeters (variant of PPG)
are being used extensively for heart monitoring [27,9395]. It
measures multiple PPG signals at different wavelengths viz., red
(660 nm) and infrared (940 nm). Pulse oximeters have been used for
sleep apnea detection [27], pulse wave velocity calculation [93],
hypoxia detection [94], and heart rate turbulence analysis [95]. Pulse
oximeters have been developed as an in-ear sensor for cardiovascular
monitoring [27,94]. This setup of sensor could offer three important
advantages: (1) comfortable to wear and hence, suitable for longterm monitoring, (2) the tight-tting could reduce interference from
motion artifacts, and (3) robustness to conditions such as temperature or skin perfusion.
However, PPG signals get contaminated primarily due to
ambient light, motion artifacts and other physiological process.
To extract information from the contaminated PPG signals, Madhav et al. [96] proposed a multi scale principal component analysis
based algorithm. In this algorithm, noise suppression from the PPG
signals was achieved using wavelet decomposition and reconstruction. Selection of coefcients to reconstruct relatively clean
signal was done based on two measures, energy contribution level
(ECL) and Kurtosis. After reconstruction of the clean signal,
principal component (PC) analysis was performed to extract
information about the respiratory system. Li and Warren [93]
developed a sensor circuit in which photodetecters are radially
distributed around the LED to increase the sensing area. This setup improved the signal quality without ltering algorithm.
Whereas, Stuban and Niwayama [97] analyzed optimal corner
frequency of low pass lter for PPG signal. Setting the corner
frequency to the fundamental frequency of the PPG signal resulted
in decreased noise, and consequently, decreased standard deviation. de Haan and Jeanne [98] analyzed robustness of the chrominance based algorithms to separate motion induced distortion
from rPPG signals in case of modest and vigorous motion.
9. Use of mobile
The latest generation of mobile phones (smartphones) is
increasingly used for health monitoring, due to their powerful
on-board computing capability, large memory, large screens and
open operating systems that encourage application development.
Technical features of mobile phone including text messaging,
camera, internet access, inbuilt sensors, make it an appropriate
platform for improving health care service [99]. Wireless technologies, including GPRS, GSM, 3GSatelite, Wireless, Lan networks,
have been used for wireless transmission of the heart signal [100].
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
10. Conclusion
In this paper we have provided a detailed review of recent
advancements for portable heart monitoring systems. We considered ECG, PCG, PPG, and SCG based systems and portability of such
systems are feasible due to use of light weight and small size body
11
12
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113
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13
Puneet Kumar Jain was born in Rajasthan, India, in 1988. He received his bachelor
of technology degree in computer science and engineering from the University of
Rajasthan in 2009 and master of technology degree in information system from
Delhi Technological University in 2011. He is currently a research scholar at Indian
institute of technology Jodhpur. His research interest includes image processing,
biometric system and biomedical signal processing.
Anil Kumar Tiwari received the master of technology degree in 2001 from the
Indian institute of technology Kharagpur and the Ph.D. degree in electronics and
communication from the Indian institute of technology Kharagpur in 2005. He is
currently an assistant professor at Indian institute of technology Jodhpur. His
research interest are in Image Processing, Video Processing and Signal Processing
application in Bio-Medical.