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Computers in Biology and Medicine 54 (2014) 113

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Computers in Biology and Medicine


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

Heart monitoring systemsA review$


Puneet Kumar Jain n, Anil Kumar Tiwari
Center of Excellence in Information and Communication Technology, Indian Institute of Technology Jodhpur, Rajasthan, India

art ic l e i nf o a b s t r a c t

Article history: To diagnose health status of the heart, heart monitoring systems use heart signals produced during each
Received 15 April 2014 cardiac cycle. Many types of signals are acquired to analyze heart functionality and hence several heart
Accepted 12 August 2014 monitoring systems such as phonocardiography, electrocardiography, photoplethysmography and
seismocardiography are used in practice. Recently, focus on the at-home monitoring of the heart is
Keywords: increasing for long term monitoring, which minimizes risks associated with the patients diagnosed with
Heart monitoring system cardiovascular diseases. It leads to increasing research interest in portable systems having features such
Cardiovascular diseases as signal transmission capability, unobtrusiveness, and low power consumption. In this paper we intend
Cardiography to provide a detailed review of recent advancements of such heart monitoring systems. We introduce the
Electrocardiography
heart monitoring system in ve modules: (1) body sensors, (2) signal conditioning, (3) analog to digital
Phonocardiography
converter (ADC) and compression, (4) wireless transmission, and (5) analysis and classication. In each
Photoplethysmography
Seismocardiography 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.

1. Introduction diagnosis reduces the mortality caused due to CVD which ensues
economic up-lift of the country [5].
Worldwide, the number of patients of cardiovascular diseases Due to the problems mentioned above, a lot of work has been
(CVD) is huge [1]. Mortality caused by CVD in 2008 was 17.3 done in development of a diagnostic efcient system [610].
million which represents 30% of global deaths. In the U.S. alone, Keeping in view that heart monitoring systems would be used in
2200 persons lose their life due to CVD each day [2]. According to different socio-economic conditions, rural-urban population, and
American Heart Association (AHA) report, the total cost of CVD deciency of availability of cardiac experts [11], recent research is
and stroke in the U.S. for 2008 is estimated to be 298 billion dollar focused towards system features such as cost effective, portability,
[1]. 80% of the total mortality caused by CVD occur in low and easy diagnose process, and signal transmission capability. In view
middle-income countries. of these developments, we propose a review of various work done
These gures indicate need of systems that should be (1) sensi- in this area.
tive to detect CVD at early stage, (2) capable of continuous Portable heart monitoring systems are used in two manners, as
monitoring, (3) light weight for portability, (4) cost effective. Lack shown in (Fig. 1), one is on-site and other is off-site. In on-site
of early stage detection and hence delay in medication causes monitoring, the acquired heart signal is processed on the patient
heart diseases to extent at a level where it is difcult to cure [3]. site, without transmitting it to the remote site. While in off-site,
Persons diagnosed with CVD need continuous monitoring of the acquired heart signal is transmitted to a remote site using
health status of their heart as they are at a higher risk to their a wireless module. On-site heart monitoring system has advan-
lives as compared to the normal persons. According to the Heart tages in the case of low latency feedback is required or wireless
Association, people diagnosed with CVD have 46 times higher access is not accessible. Furthermore, it eliminates data transmis-
mortality than normal one [4]. Portability of such systems makes it sion and hence eliminates the radio power consumption. However,
highly useful for elderly patients as this minimizes visits to clinics the on-site monitoring has limitation that it has only a set of
or hospitals. A cost effective system will emphasis the use of heart general diagnosis steps and thus unable to perform a detailed
monitoring systems in low and middle income countries. Proper diagnosis. On the other hand, in off-site monitoring, diagnosis is
performed at remote location with high computation capable
processors and supports input from a cardiologist. This makes it
suitable for accurate and detailed diagnosis. It is attractive because

This paper was not presented at any IFAC meeting.
of higher processing capability and less power restrictions on such
n
Corresponding author. Tel.: 91 9252903393. remote computation. Off-site monitoring also reduces the false
E-mail addresses: puneetjain@iitj.ac.in (P.K. Jain), akt@iitj.ac.in (A.K. Tiwari). alarm rate and thus reduces visits to clinics or hospitals. In view of

http://dx.doi.org/10.1016/j.compbiomed.2014.08.014
0010-4825/& 2014 Elsevier Ltd. All rights reserved.
2 P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113

Fig. 1. Heart monitoring system.

these advantages of off-site monitoring, this paper is intended to


provide a detailed review of recent research in the off-site
monitoring system.
A typical off-site heart monitoring system consists of ve
modules as shown in (Fig. 2). The system with rst four modules
body sensor, signal conditioning, ADC and compression, and
wireless module is situated at the patient site. While the fth
module that is analysis and classication module is situated at
remote site which can be any computational device with high
computational ability.
Heart monitoring system uses signals produced by heart to
diagnose its health status. It extracts diagnostic features from the
acquired signal which caries information of heart functionality
such as re-polarization, depolarization, and valve movements.
Analysis of these features leads to specic health status of heart
such as normal, arrhythmic, myocardial infarction, regurgitation,
and stenosis. However, extraction of diagnostic features from the
heart signal is challenging due to its non-stationary nature and the Fig. 2. Off-site heart monitoring system.
presence of noises such as muscles movement noise and environ-
ment noise in the signal. In this paper, we reviewed recent Heart is a prominent organ of human body. It supplies
developments in the area of heart monitoring systems which are replenish oxygen to each part of the body and removes waste of
portable and have good diagnostic efciency. each cell. Physiologically, heart comprises of four chambers named
Rest of this paper is organized as follow. Physiology of heart as left and right ventricles and left and right atrium as shown in
and cardiac cycle in Section 2 and brief introduction about Fig. 3. There are two atrioventricular valves namely tricuspid valve
important cardiovascular diseases in Section 3 are given for read- and mitral valve. As can be seen in Fig. 3, tricuspid valve separates
er's simplicity. Section 4 describes the recent developments in the right atrium and right ventricle while mitral valve separates left
body sensors. While different approaches of signal conditioning atrium and left ventricle. Aortic valve and pulmonary valve jointly
have been reviewed in Section 5. In Section 6, analog to digital called as semilunar valves separate left and right ventricles from
conversion and compression techniques are presented. Section 7 aorta and pulmonary artery respectively. At rest, each cell of the
discusses various wireless transmission technologies and Section 8 heart muscle has a negative charge, called the membrane poten-
gives comprehensive review of noise removal algorithms, analysis tial. Due to rapid change of membrane potential towards zero, due
and classication techniques for heart signals. Conclusion and to inux of positive cations (Na and Ca ), an electrical
potential research area have been presented in Section 10 followed impulse is generated at sinoatrial node. From sinoatrial node, the
by important references. impulse spreads over both the atrium and both the ventricles.
Presence of the impulse causes the contraction of atrium and
ventricles sequentially.
Contraction of both atrium pushes the blood into respective
2. Physiology of heart and cardiac cycle ventricles. Then the impulse spreads all over left and right
ventricles which causes the contraction of both the ventricles.
Since understanding of various components of heart monitor- This contraction results to closing of both atrioventricular valves
ing systems needs knowledge of heart functioning, a relevant and opening of both semilunar valves. During this contraction
physiology of heart is described in this section. phase, oxygenated blood from left ventricle ows into the body
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113 3

signal. Fig. 4 shows signals of one cardiac cycle acquired using


electrodes, stethoscope, accelerometer, and diode as
described below.

4.1. Electrodes (electrocardiography)

Initial electrocardiography (ECG) was based on string galvan-


ometer 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
Fig. 3. Anatomy of the human heart.
the relaxation of inter-ventricular septum. Thus duration and
amplitude of these waves provide signicant information for
through aorta while deoxygenated blood from right ventricle ows diagnosis of health status of heart.
into the lungs through pulmonary artery for oxygenation. Since Extraction of duration and amplitude of some of the waves (P, T
body and lungs receive blood due to contraction process, pressure and U) is difcult due to very weak amplitude, typically in the
in body lungs becomes higher than pressure in atrium. Due to this range of 100300 V [14]. ECG signal lies in frequency band of 1
pressure difference, now, blood ows into left and right atrium 250 Hz, where icker noise is dominant and common-mode
from lungs and body respectively. This process completes a interference from the main power line is likely to interfere with
cardiac cycle.

3. Important cardiovascular diseases

Heart beats 100,000 times and pumps 2000 gallon blood in


a day [12]. Heart function gets affected due to many factors such as
psychosocial stress, smoking, excessive use of alcohol, malnutri-
tion, lack of physical activity, and congenital diseases [13]. These
factors may affect electrical activity of heart, structure of heart,
and arteries. Due to these defects, different heart diseases occur.
Dysfunction of electrical conduction system causes diseases such
as sinus arrhythmia, atrial uttering, atrial brillation, ventricular
brillation, atrioventricular block, and bundle branch block.
Defects in structure of the heart cause regurgitation, stenosis,
enlargement of chambers, ventricular septum defect, etc. Defects
in arteries cause hypertension, stroke, myocardial infarction, etc.
According to American Heart Association report [2], following
are the most common heart diseases. Myocardial infarction (heart
attack), which occurs due to blockage in coronary arteries which
supply blood to the heart cells. Insufciency of blood supply
causes dying of the heart cells and consequentially heart muscles
lose pumping capacity. Hypertensive heart diseases occur when
the blood pressure in arteries is much higher than the normal.
High pressure causes stiffness of arteries, consequentially blood
ow gets affected. Arrhythmia is fast and irregular beating of the
heart. Congenital heart diseases are those which are present at the
time of birth. Heart failure is a condition which indicates inability
of the heart to pump the blood. Mortality caused by myocardial
infarction was 21.6% of all mortality due to CVD in U.S., while 9.2%
by hypertensive heart disease, 5.7% by arrhythmia, 8.0% by con-
genital heart diseases, and 6.9% by heart failure was accounted [2].
Since heart problems need diagnostic system, the following sec-
tion discusses about body sensors used to acquire heart signal for
this purpose.

4. Body sensors

Different body sensors acquire heart signals in different forms Fig. 4. Signals of one cardiac cycle: (a) electrocardiography signal, (b) phonocardio-
such as electrical signal, acoustic signal, seismic signal, and optical graphy signal, (c) seismocardiography signal, and (d) photoplethysmography signal.
4 P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113

ECG signal [15]. To overcome these problems signal conditioning, 4.2. Stethoscope (phonocardiography)
discussed in Section 5, is essential.
Major problem with ECG is to establish good electrical con- Stethoscope was invented by Ren Laennec in 1816. It is
ductivity between skin and electrodes. Some of the ECG sensors, basically a transducer which converts vibration signal into acoustic
widely used in practice, can be classied into following three signal. A phonocardiogram (PCG) is a plot of acoustic signal,
categories. acquired by stethoscope. Stethoscope makes PCG a highly porta-
ble, low cost, and non-invasive cardiography technique [10]. PCG
signal, as shown in Fig. 4(b), consists of two classical heart sounds
4.1.1. Wet sensors
known as S1 (Lub) and S2 (Dub). S1 is generated due to closing of
In these type of sensors, AgAgCl electrodes are attached to the
the tricuspid and mitral valves. It is composed of energy in 40
skin using gel which provide a conducting medium for charge
65 Hz frequency band and 130200 ms time duration [10]. S2 is
transfer between the electrodes and the body [6]. These sensors
generated due to closing of aortic and pulmonary valves and lies
provide good signal quality, but it is inconvenient in terms of long
within 4565 Hz frequency band and 100150 ms time duration
term wear-ability due to use of gel which creates irritation and
[10]. Period between S1 and S2 is called as systole, while S2S1
etching problem [6]. Moreover, For signal acquisition, attachment
phase is called as diastole. There are two more components in PCG
of electrodes to different points on the body restricts patient's
signal called S3 and S4 and they rarely occur. Murmurs are
mobility. The acquired signal quality may deteriorate due to sweat
additional sounds that lie within a frequency band of 100
[16] and due to gel dehydration [17].
500 Hz [10]. They indicate diseases in heart such as aortic stenosis,
pulmonary stenosis, mitral regurgitation, and mitral stenosis.
4.1.2. Dry sensors Stenosis and regurgitation are valvular diseases caused by stiffness
These sensors use a metal plate direct placed on the skin of valves and improper closing of valves respectively. Stenosis
without the use of gel. Thus the problem of irritation and etching restricts proper blood ow, while regurgitation causes blood to
caused by gel has been eliminated [18]. Although, it still has ow in opposite direction to the normal [10]. PCG has high
a direct contact with the skin. Dry sensors are robust to environ- potential to detect these valvular diseases and important cardio-
ment noises and sweat noise but more vulnerable to motion noise vascular diseases except myocardial infarction and congenital
compare to wet sensors. Quality of the signal acquired using these heart diseases. However it indicates the abnormality caused by
sensors depends on the composition of the materials and the size myocardial infarction and congenital heart diseases. PCG signal
of the electrode [17]. Increasing size of the electrode gives better may get contaminated by noises occurring due to breathing,
capacitance and consequentially good signal quality but it movement of stethoscope while recording, ambient sources, etc.
decreases the patient's convenience. As a result of these noise problems, many ltering techniques have
been developed to minimize affect of noise on PCG signal. Detailed
4.1.3. Capacitive coupled sensors discussion about the same is given in Section 8.
Capacitive coupled (CC) sensors avoid direct contact with the
skin that minimizes patients' inconvenience as stated in the 4.3. Accelerometer (seismocardiography)
previous subsections, (a) and (b). A thin layer of insulator is placed
between the body and metal-plate sensing electrode [6]. The Seismocardiography (SCG) is another non-invasive technique
electrode, together with the skin and insulator, forms a capaci- because it works using accelerometer, a non-invasive device.
tance that conveys the ECG signal from the body to the sensor. It measures mechanical vibrations which are generated by heart
Sensitivity of such sensors increases with the value of capacitance, movement and transmitted to the chest wall [23]. As shown in
which can be increased by increasing electrode area, by reducing Fig. 4(c), SCG contains waves corresponding to atrial contraction
thickness of insulator, and by using insulator with high dielectric (ATC), mitral valve closing (MC), aortic valve opening (AO), point of
constant. General expression of capacitance is given as follows: maximal acceleration in the aorta (MA), aortic valve closure (AC),
mitral valve opening (MO), and rapid lling of left ventricle (RF)
0 A [24,25]. Shapes of these waves give signicant information about
C 1
d health status of heart. SCG is convenient to patients, as there is no
where 0 is the dielectric constant, A is the electrode area, and d is need of multiple electrode contacts as in ECG. However, obtaining
the thickness of insulator. CC sensors have been developed on a clean SCG signal from an accelerometer is difcult, because of
chair [19,20], on bed [21] and textiles [22]. Development of sensors interference due to breathing.
on chair, bed and textiles supports continuous heart monitoring
even when working in ofce and sleeping. CC sensors are highly 4.4. Diode (photoplethysmography)
sensitive to motion noise as in case of dry sensors. This is because,
a movement of electrode changes the coupling capacitance and In photoplethysmography (PPG) uorescent body parts such as
consequentially the acquired signal [6]. earlobe and nger are illuminated with lights of different wave-
A comparative study between three types of electrodes is lengths emitted from light emitting diodes (LEDs). Then intensity
presented in (Table 1). For clinical use, where simplicity of of transmitted or reected light is measured by photo-diode [26].
operation, less processing time, and good signal quality are The measured intensity varies in time with the heart beat because
preferred, wet sensors are suitable. Additionally, the availability, blood vessels expand and contract with each heartbeat. The PPG
relative cheapness, and disposability of wet electrodes overcome waveform is composed of an ac component and a quasi-dc
hygiene concerns. While, the dry and capacitive electrodes are component [27], as shown in Fig. 4(d). The ac component is
convenient in use, and consistent in performance. These features associated with heart beat and has fundamental frequency typi-
make these sensors suitable for long term, and unsupervised cally around 1 Hz. The quasi-dc component, superimposed with ac
monitoring. However, the performance of these types of electrodes component, relates to the respiration system. As the ac component
depends on the electrode geometry. Furthermore, these electrodes of the PPG signal is in synchronization with heart beat, informa-
require proper shielding and settling time to perform comparable tion about heart rate can be extracted from it. PPG uses LEDs and
to, or better than wet electrode. Researchers in the past have made photo-diode which makes it low cost, non-invasive, easy to use
numerous attempts to overcome these problems [16]. and portable system. Since it operates optically, it is not
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113 5

Table 1
Three types of electrodes.

Characteristics Wet electrodes Dry electrodes Capacitive electrodes

Signal acquisition AG/AGcl electrodes, uses electrolyte Benign metal (stainless steel), no Metal or semiconductor, no direct
electrolyte contact
Signal quality Low contact impedance ensues good Depends on electrode geometry Depends on electrode geometry
signal quality
Consistency Gel dehydrate with time, After settling time good performance After settling time good performance
which reduces quality of the signal due to reduction in skin/electrode due to reduction in skin/electrode
interface interface
Convenience Use of electrolyte cause etching Direct contact with skin, which may No direct contact, fabricated in cloth,
problem, removal of gel is unpleasant cause irritation chair, bed, that increases convenience
and time consuming, and toxicological to user
concern
Size Lightweight Heavy due to shielding Bulky due to required circuitry for
buffers and extra cables for power
Noise vulnerable Moving charge sensitivity Movement artifact Motion and environment artifact,
electric eld problem
cost Lower cost Expensive Expensive

intrinsically susceptible to capacitive coupling interference as in PPG is the most suitable technique in terms of portability and
ECG [28]. However, photo-diodes are sensitive to natural and used widely for heart rate calculation. Problem with the ECG is that
articial light sources. PPG based heart monitoring systems are it uses a gel which causes etching problem, and reduces comfort of
unobtrusive as size and weight of the device of PPG is low. PPG is the patient and hence reduces acceptability for long term monitor-
generally used in direct contact with the patient's skin as in the ing. PCG has advantages over ECG in terms of comfort of the patient
case of other systems (ECG, PCG, SCG). But in the case of neonates, and easy to operate. SCG is superior to the PCG in terms of comfort
skin-damage, direct contact to skin is not feasible and hence because of the low weight (o3 g) accelerometers.
Huelsbusch and Blazek [29] proposed a remote PPG (rPPG) that
can acquire PPG signal without the contact with skin. The main
concern with rPPG is its sensitivity to the subject motion. 5. Signal conditioning
Portability of the system is induced by small size and low
weight sensor, used by the system. ECG, PCG, SCG and PPG are Heart signals, acquired by different body sensors, often get
portable as they satisfy these conditions. Portable diagnostic contaminated by noise components such as icker noise,
system is useful in many scenarios. Most use of the portable common-mode interference, power-line interference, and baseline
system is for long term monitoring, which is required for acute wandering [15]. Also, amplitude of the acquired signal is typically
symptom detection and early diagnosis of the heart diseases. low. A signal conditioning module typically consists of algorithm
However the acceptance of a portable system depends on the for noise minimization and amplier to amplify low amplitude
diagnostic efciency, performance of the system in different signals. This module operates on signals in analog domain. Power
environmental conditions, comfort to the user, easy to operate, consumption of this module used to be low so as to support long
and cost. term operability of heart monitoring systems. For the same
ECG signal contains information about the electrical activity of purpose, Rieger [30] proposed a variable gain circuit consisting
the heart. Thus provides better insight on the issues related to of a continuous-time input stage using lateral bipolar transistors.
electrical conduction abnormality of the heart. While the PCG Spinelli et al. [31] proposed a driven right leg circuit to reduce
signal acquires acoustic sounds produced by the heart valves common-mode interference. Gomez-Clapers and Casanella [18]
(mechanical action) and thus useful in diagnosis of the valvular used dual ground conguration to reduce the noise caused by
diseases. Due to different source of producing these signals (ECG power line interference and base line wandering. Since most of the
and PCG), the existence of a problem (e.g. structural abnormalities) heart monitoring systems are digital in nature and need commu-
in PCG signal does not imply the existence of the same problem in nication for remote monitoring, the following section discuses
ECG signal and vice versa. SCG signal is also produced by the about analog to digital conversation (ADC) and compression
mechanical action (acceleration of the heart), measures compres- algorithms.
sion waves. Acceleration is a second derivation of the displace-
ment and that is why SCG signal contains more information
compared to the PCG signal. PPG signal provides only limited 6. Analog to digital conversion and compression
information about the heart. It measures the blood variation in the
blood vessels. Although, with the combination of ECG or PCG it has Heart signals (analog) are converted into digital signals for its
been used for the calculation of pulse transit time (PTT), which is processing on digital computers. This is done by sampling the heart
an important diagnostic parameter in the case of obstructive sleep signal and quantizing the sampled values. This process is done on
apnea detection and blood pressure measurement. Digital Signal Processor (DSP) called Analog to Digital Converter (ADC).
For clinical use, all methods are suitable as signal to noise ratio Selection of the DSP depends on the desired sampling rate, number of
(SNR) remains high. At home, in the presence of the environ- bits to be used for quantisation, operating frequency and power
mental and motion noise, robustness of the sensor to the noises is consumption. As described in Table 2, MSP based processors have
a major issue. In case of ECG, as discussed in (Table 1), wet sensors lower power consumption compared to the PIC based processors,
are robust to noise while dry and capacitive sensors are vulnerable while the PIC based processors have higher operating frequency
to noise. PCG is more vulnerable to patient's motion noise and compared to the MSP based processors. Both types of processors
environmental noise compared to the ECG. On the other hand, SCG provide multiple working and idle modes according to the required
is robust to the motion noise and environmental noise. computational power, to optimize the power consumption. DSP with
6 P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113

low power consumption supports long term monitoring of the heart. considered to be non-adaptive because measurement matrix []
To optimize the power consumption, Bachmann et al. [32] proposed a remains constant.
DSP with the capability to perform in different power modes accord- Several measurement matrix design considerations and recon-
ing to the required accuracy and available computational power. struction algorithms have been presented in [39] and found that
Power consumption was optimized at different abstraction layers from using Bernoulli measurement matrix, compression ratio of 16 is
application optimization and mapping to system. achievable. Mamaghanian et al. [40] compared CS and the DWT-
Conventional sampling techniques, sample signals at or above based compression algorithms and found that CS was inferior to
Nyquist rate, which ensues perfect reconstruction of the signal. DWT-based algorithm in compression performance. Despite of it,
Nyquist rate is twice the maximum frequency component present CS-based compression outperforms in terms of energy efciency
in the signal to be sampled. Typically, heart signal components are due to its lower complexity and reduced CPU execution time.
below 1 kHz frequency and hence, as per Nyquist rate, 2 K samples After digitization of analog signals, digital signals are com-
per second are sufcient to avoid aliasing error. However, even 2 K pressed to reduce amount of data. The basic purpose of data
samples per second sampling rate generates a huge number of compression is to represent the original signal with a smaller
samples, if the heart is monitored for a long time. Consequentially, number of bits than that is needed for the original signal. The
the power requirement of DSP increases as the number of samples compression is typically achieved by removing redundancy from
to be processed is huge. In spite of it, compressed sensing (CS) the signal to be compressed. Since power requirement of wireless
enables sub-Nyquist sampling of signals. module directly depends on the amount of data to be transmitted,
Compressed sensing (CS) is a data acquisition approach that one of the major advantages with compression is a reduction in
requires only a few incoherent measurements to compress signals power requirement by wireless module. However, there is a loss of
that are sparse in some domain [38]. Let [] be an original input information, in general, when signal is reconstructed from the
vector of dimension N  1 and [] is the N  N sampling basis or compressed data. A proper balance is maintained with compres-
sparsifying matrix containing orthonormal basis (such as a wavelet sion ratio and the requirement that the information of diagnostic
basis) [ 1 ; 1 ; ; n ]. Then [X], sparse in [] domain with length importance is preserved.
N can be found as Heart monitoring systems have additional requirement for
compression algorithms to be computationally efcient to support
X  2
long term monitoring. Various compression algorithms for heart
Then output compressed vector is dened as signals have been reported in the literature. Wavelet transform
[41,42], Walsh transform [43], Hermite function [44] and discrete
Y X 3
cosine transform [45] based compression algorithms rst decom-
where [] is the M  N measurement or sensing matrix. So, we get pose the signal into coefcients, by projecting the signal onto basis
an output vector [Y] with length M, where M oN. CS captures M functions of transforms. Then compression is achieved by retain-
measurements from N samples using random linear projections. ing only a small number of coefcients which typically preserves
Now, as the lower number of measurements were taken than the essential information of the heart signal. As stated before, compu-
original signal, non-linear optimization techniques are used to tational complexity is crucial for the compression algorithm as
reconstruct the original signal [38]. Reconstruction of the signal these have to be implemented on the patient side. Computational
can be achieved as complexity of DWT is O(N), DCT is O(NlogN), Walsh transform is O
b J1 b (NlogN), and Hermite function is O(Nlog2N). Thus DWT has lowest
Min J X subject to Y X 4
computational complexity. However, compression performance
Perfect reconstruction of the signal depends on the incoherence of the Hermite function based method is better than DCT and
between [] and [] matrices. Thus, random matrices can be used DWT based basic compression algorithms [44]. The performance
as a measurement matrix because random matrices are, with high of these algorithms depends on the following parameters:
probability, highly incoherent with any xed basis []. CS is (a) choice of basis function, (b) decomposition level, and (c) the

Table 2
Digital signal processors.

Processor No. of bits Operational frequency (MHz) Power consumption Used in Characteristics

PIC24FJ64GA 10 32  Run mode: 650 A at 2.0 V, 1 MHz [6]  Low operating voltage range
 Idle mode: 150 A at 2.0 V  On-the-y clock switching
 Sleep mode: 0.1 A at 2.0 V
PIC18f2423 12 40  Run mode: 330 A at 2.0 V, 1 MHz [33]  Multiple idle and run modes
 Idle mode: 5:8 A at 2.0 V  Nano watt technology
 Sleep mode: 0:1 A at 2.0 V  On-the-y clock switching
PIC16F877 8 20  Run mode: 600 A at 3 V, 4 MHz [34] High performance RISC CPU
 Idle mode: 20 A at 3 V, 32 kHz
 Sleep mode: 1 A
MSP430f2274 10 16  Run mode: 270 A at 1 MHz, 2.2 V [18,35]  Ultra-fast wake-up
 Idle mode: 0:7 A  Ultra-low power
 Sleep mode: 0:1 A  RISC mixed-signal microprocessors
MSP430F1611 12 8  Run mode: 330 A at 1 MHz, 2.2 V [36]  Ultra-fast wake-up from stand-by
 Idle mode: 1:1 A  Five power saving modes
 Sleep mode: 0:2 A
MSP430F2410 12 16  Run mode: 270 A at 1 MHz, 2.2 V [37]  Ultra-fast wake-up
] Idle mode: 0:3 A  Ultra-low power
 Sleep mode: 0:1 A
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113 7

percentage of retained energy (number of coefcients). In these systems. In the literature, various wireless communication tech-
approaches, trade-off between the percentage of retained energy niques and protocols have been proposed for transmission pur-
and compression ratio is crucial. Increment in the percentage of pose (Table 3). Bluetooth 4.0 [37] wireless system supports
retained energy reduces compression ratio and enhances recon- 24 Mbps data rate, has working range up to 100 m, and consumes
structed signal quality and vice versa. Retained coefcients are low power. Bluetooth devices with these features are suitable to be
compressed using conventional compression algorithms such as integrated with heart monitoring systems. But Bluetooth wireless
zero-removal [41], Huffman coding [41,42], dead zone quantiza- systems require initial connection setup that has to be done
tion [45], and run length coding [42,46]. While, Sharma et al. [47] manually. Patient's intervention is not desirable in a heart mon-
applied multi-scale principal component analysis (MSPCA) on itoring system as it reduces convenience. To overcome this
wavelet transform coefcients and then MSPCA coefcients are problem an approach was proposed by Morak et al. [37] using
uniformly quantized and encoded by Huffman coding. All the radio-frequency identication (RFID) and near eld communica-
above algorithms compressed the entire frame with same com- tion (NFC). In this approach, the connection establishes by bring-
pression ratio. On the other hand, researchers have been proposed ing two NFC enabled devices closer and using RFID information of
approaches to use different compression ratio for different block of both devices. The drawback of this approach is that it requires
signals [43,46,48,49]. Different statistical parameters have been permanent activation of Bluetooth which results in extra power
calculated to identify signicance of the segment such as Wang consumption. Moreover, NFC can support data rate up to 424 kbps
et al. [48] calculated kurtosis, Kim et al. [49] calculated mean only. Since data rate is lower than Bluetooth 4.0, it takes long time
deviation (MD), Ma et al. [50] calculated wavelet coefcient to transmit data. A good review of the state-of-the art technologies
energy. In [43], signicance of the segment is calculated based for wireless network was presented by [32].
on the energy of the Walsh coefcients. While, Rajoub [46] applied Keeping in view the desired features of wireless module,
DWT and then divided the coefcients into three groups based on various protocols have been proposed [6,36]. Chen et al. [36]
magnitude of coefcients and then applied different thresholding proposed a reliable protocol based on any-cast routing algorithm.
for each group. This algorithm automatically selects nearest hop (sink), in case of
Researchers have also proposed compression algorithms that failure in original path, instead of rebuilding the path from the
preserve features of heart signal (rather than preserving the source node. Thus, it provides a reliable communication as well as
waveform) [51,52]. In [51] Alvarado et al. proposed a compression reducing trafc overhead and transmission latency. However,
algorithm based on integrator and re sampler. Similarly, Kim selection of the hop process increases the complexity of routing
et al. [52] proposed an algorithm based on curvature points, which algorithm and the complexity increases power consumption. To
calculated the important information from the signal. optimize power consumption, Nemati et al. [6] proposed an ANT
Compression algorithms which require low computation are protocol. The ANT protocol was used as a low-data-rate wireless
suitable for long term heart monitoring. DWT based compression module to reduce the power consumption and size of the sensor.
algorithms have lower computational complexity than other ANT is an adaptive isochronous ad hoc wireless protocol based on
algorithms and thus have been used extensively. On the other master slave model. It consumes from 1 mA to 6.3 mA current and
hand, feature preserving compression algorithms have high com- supports many topologies such as peer-to-peer, star, tree, and
pression ratio. They are suitable for heart signals because diagnosis mesh. SimpliciTI is also a low power radio frequency (RF) network
can be performed based on these features. However, selection protocol used in heart monitoring systems [18,35]. SimpliciTI was
process of the diagnostic features from the heart signal is complex designed by Texas Instruments for easy implementation and
process. Furthermore, the performance of these types of algorithm deployment on RF platforms. It is low data rate and low duty
deteriorated in the presence of noises. cycle protocol and supports star and peer-to-peer network
topology.
Ma et al. [50] proposed an unequal-error protection approach
7. Wireless module for heart signals to reduce transmission distortion and to reduce
power consumption of wireless transmission. In this approach
Digitized and compressed heart signals are transmitted to more protection is provided to the segment of heart signal which
remote site. In off-site monitoring, analysis and classication of contains diagnostic important features compared to the other
the heart signals are performed at the remote site. Transmitter segments. Results showed that nearly 40% of transmission energy
consists of wireless module which helps to transmit heart signals can be saved compared to the equal error protection.
to remote site. Low power consumption, convenient connection In a different approach, Atakan et al. [53] introduced the concept
process, and low latency are some important features of wireless of a body area network (BAN) with molecular communication,
modules that promote wide acceptance of heart monitoring where the messenger molecule is used as a communication carrier

Table 3
Wireless modules.

Module Power consumption Size (mm) Transmission range (m) Manufacturer Used in

Receive Transmission

CC2420 (zigbee) 18.8 17.4 77 70 Texas instruments [54]


Bluescense (blutooth) 33 37  21 Corscience [55]
nRF24E1 (Eco-wireless) 22 10 13  11 10 UC Irvine [56]
ANT-AP2 17 15 20  20 30 Dynastream Innovations [6]
cc2500 (zigbee) 13.3 21.2 44 30 Texas instruments [18,35]
UZ2400 (zigbee) 18 22 66 Uniband Electronics Corp. [36]
Zebra (zigbee) 16  33 10500 senTec Elektronik [57]
BlueNiceCom-4 (bluetooth class-2) 65 27  16 20 AMBER wireless [37]
Xbee (Emosense) 50 45 24  27 3090 Digi International Inc. [58]
8 P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113

from a sender to receiver. However, the communications at the does not change abruptly from a cardiac cycle to consecutive
molecular scale are subject to numerous problems, some similar to cardiac cycle. Thus, noise suppression can be achieved by correlat-
the ones faced on a larger scale in existing wireless networks. ing the consecutive cycles of the signal because noise components,
in general, are uncorrelated. However, quasi-cyclostationary nat-
ure of the heart signal may not be fullled due to variation in
8. Analysis and classication waveform, presence of murmurs, and variation in the timing of the
heart sound components. Furthermore, the performance of this
Analysis and classication module performs automatic approach depends on the segmentation of cycle.
machine diagnosis that enhances diagnostic accuracy. It is very Adaptive noise cancellation (ANC) techniques are also found
helpful in the present scenario, where the number of cardiologists suitable for heart signals as they can detect dynamic variation in
is low when compared to the number of cardiac patients [5]. the signal [65]. Least mean square (LMS) is an ANC technique
Typically, analysis and classication is performed in two steps: which calculates lter coefcients that relate to producing the
noise suppression, and analysis and classication. In noise sup- least mean squares of error signal (difference between the desired
pression step, noises are suppressed from heart signals. In the next signal and the ltered signal). Estimation of lter coefcients
step, the heart signals are classied in normal and different CVDs. requires high computation. To reduce the computation of LMS
algorithms, various variations in LMS algorithms have been
8.1. Noise suppression proposed in the literature and reported in [65]. To further reduce
the computational complexity, the author proposed [65] sign and
Noise suppression from heart signals is essential as its presence error non-linear sign based LMS.
may lead to imprecise or inaccurate classication of the signals. Respiratory system also affects heart signals signicantly. To
For noise suppression, classical lters such as Gaussian lter, overcome this problem, Chen et al. [66] proposed a zero crossing
Chebyshev lter, Butterworth lter, and Weiner lter have been method. It calculates the time interval between two consecutive
used extensively. Because, heart signals lie in the 20500 Hz upward and downward points (IBI) in the signal. Then the inverse
frequency band and these lters are able to suppress noise in of IBI gives the frequency of breathing signal, which can be
the selected frequency band (below 20 Hz and above 500 Hz). But removed by notch ltering.
noises, which overlap with spectral contents of heart signals, are Noise often appears in parts of the heart signal recordings.
not easy to suppress from the signals. Hence, sophisticated lters In some part, noise affects severely to the heart signal while in
have been proposed in the literature for suppression of these types others it affects mild. In the case of severe contamination, that
of noises (in-band noise) [59,60]. Filters have been developed part of the signal can be eliminated from diagnostic considera-
based on wavelet transform [59]. In these lters, signals are tion while in the case of mild contamination, noise suppression
transformed into wavelet coefcients, as discussed in Section 6. algorithm can be used. This approach will improve diagnosis
Then noise suppression is achieved by discarding the coefcients efciency as well as optimize complexity of denoising algo-
which are correlated to noises, by applying threshold. Although, rithms. This approach will be also helpful in home care systems
wavelet based lters are able to suppress the in-band noise, but for alarming to the user for the bad signal quality. Thus, it is of
the threshold value plays a crucial role in this approach. If the interest to obtain a signal quality index to nd out a subse-
threshold is selected high, signal information will be lost, while quence with better signal quality with respect to the rest of the
small value will not have a signicant effect on the signal. To cycle. Li et al. [67] proposed an optimum heart sound selection
obtain optimal denoising parameter for DWT based denoising, scheme based on cycle frequency spectral density. In this
Messer et al. [61] performed experiments and found that level approach, the quality of the heart sound signal depends on the
5 for the signal decomposition and soft thresholding with rigrsure periodicity of the heart signal. In [68], the quality index was
threshold selection rule gives the best result. calculated using the Cepstral distance between homogeneous
Almasi et al. [60] introduced model-based Bayesian denoising cardiac sounds. In this algorithm, rst, the heart signal was
framework which combined the extended Kalman lter and segmented into separate cardiac cycle using wavelet based
dynamic model of the heart signal. Results demonstrate that the approach. After segmentation, Mel frequency Cepstral coef-
proposed method has the superiority over wavelet based denos- cient (MFCC) was calculated for each cycle. Finally, the recipro-
ing. However, the requirement of a model of the heart signal limits cal of distance between MFCC coefcients of consecutive cycle
the use of this framework. gives the quality score. The performance of this algorithm
Researchers have proposed many ltering approaches which depends on the segmentation of the heart signal into cardiac
analyze diversity between characteristics of heart signal compo- cycle. Naseri [69] described an approach to identify the level of
nents and characteristics of noises [7,15,62]. Lee et al. [7] used rst noise in the heart signal cycle. In this approach, rst, the signal
order-intrinsic mode function (F-IMF) to minimize motion noise is segmented into separate heart cycle. Then, cycles are clus-
from the heart signals. F-IMF of the clean signal has periodic tered into a nite number of groups based on geometrical
patterns, whereas noise contaminated signal has highly varying parameter and spectral content. Next, median of these clusters
irregular dynamics with lower magnitudes. Thus, noisy segment is correlated to the test cycle features. Finally, by applying a
can be classied from the clean heart signal. Liu et al. [15] removed threshold, the cycle is prescribed as clean or noisy. Although,
the noises from heart signal components based on the character- requirement of a test cycle features limits the use of this
istic of wavelet coefcient that the signal coefcients with large approach.
magnitude at a ner scale will also be large in magnitude at
coarser scales. However, for coefcients which are caused by 8.2. Analysis and classication
noises, magnitude will decay rapidly along the scales. Manikandan
and Soman [62] calculated lag-1 auto-correlation coefcients, Analysis and classication of heart signals are challenging tasks
which give positive values for heart signal components and due to non-stationary nature of the heart signals. Moreover, time
negative values for spurious noise. to time varying morphology of heart signals from intra- and inter-
Quasi-cyclostationary nature of heart signals also has been patient needs sophisticated classication algorithms. Classication
considered to lter noise from the signals [63,64]. Quasi- of heart signals is performed by analyzing diagnostic features
cyclostationary means that the morphology of the heart signals present in the signal as follows.
P.K. Jain, A.K. Tiwari / Computers in Biology and Medicine 54 (2014) 113 9

8.2.1. Electrocardiography RR intervals. Huang et al. [76] proposed an algorithm to classify AF


ECG signal consists of different waves, as discussed in Section 4 by analyzing RR interval.
(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, hyperten- 8.2.2. Phonocardiography
sive heart diseases, arrhythmia, CHD. The impact of CVDs can be As discussed in Section 4.2, PCG signal consists of four sound
seen on the waves in ECG signal. Myocardial infarction causes ST components. Characteristics (intensity, frequency, and duration) of
elevation or depression depending on the severity of the infarc- these sound components change due to the presence of CVDs.
tion. Location of the infarction can be identied by analyzing ECG Additional murmur sounds may also be present in PCG signal due
signals of different leads. In the case of hypertension, QRS voltage to the presence of CVDs. Although PCG can indicate abnormalities
increases due to both thickening of wall (pressure overload) and caused by important CVDs, it is used extensively for diagnosis of
dilatation of chamber (volume overload) of the left ventricle. The valvular diseases as sound components are produced by the
RR interval is critical in the diagnosis of many arrhythmia such as valvular activity [10]. Valvular diseases cause systolic and diastolic
premature ventricular contractions, left and right bundled branch murmurs. Aortic stenosis (AS), pulmonary stenosis (PS), and mitral
blocks, and paced beats [70]. regurgitation (MR) cause systolic murmurs. On the other hand,
Classication of ECG signals is performed by analyzing shape of diastolic murmurs occur due to aortic regurgitation (AR), mitral
the waves presents in the signal. Parameters of the shape of the stenosis (MS) etc. Systolic murmurs, AS lies in the frequency band
waves act as features for classication algorithms. Computational of 120250 Hz, PS lies in 200250 Hz, and MR lies in 300400 Hz.
requirement of classication algorithms depends directly on the MR can be classied from other two systolic murmurs (PS and AS),
number of the features used and accuracy of classication depends as with wider duration and higher frequency band. S1 also
on quality of the features. Thus, feature selection plays a promi- becomes quieter than normal, in case of MR. Whereas PS causes
nent role in the classication of ECG signals. In the literature, many longer duration between aortic and pulmonary components of the
approaches have been proposed to select optimal features. Bashir S2, called as split S2. Splitting of S2 also may occur due to atrial
et al. [70] calculated QRS, P and T waves morphological parameters septal defect and right bundle branch block. Diastolic murmurs lie
as features to detect different arrhythmia. Then a parameter score in 100250 Hz. MS causes mid-diastolic murmur with louder S1
was calculated for an adaptive selection of feature subset for and causes a high frequency opening snap of 90130 ms after the
particular arrhythmia. Accordingly, there will be a different feature aortic component of S2. While AR is relatively louder than other
set for each arrhythmia, which enhances the accuracy, and at the diastolic murmurs. But more severe AR causes a lower intensity
same time reduces the computational burden. While, Llamedo and murmur with longer duration. Two other sound components, S3
Martinez [71] calculated interval features and morphological and S4, in PCG signal rarely occur and may indicate abnormalities.
features for classication of arrhythmia. Interval features were Presence of S3 in a child is normal, while in adults, it represents
calculated from R peaks, and morphological features were calcu- diastolic overload or cardiomyopathy [77]. S4 occurs just after
lated from three sources, RR interval, 2-D vectocardiogram loop atrial contraction and it may be due to ventricular hypertrophy or
and DWT of the ECG signal. Then outliers form the feature set pulmonary arterial hypertension [77]. Analysis of the sound
were removed based on Kurtosis coefcients. Mar et al. [72] components and the murmurs leads towards to the classication
applied sequential forward oating search algorithm with a new of the PCG signals.
criterion function index. Drawback of the proposed method is that Heart sound classication algorithms rst partition the PCG
in many cases the subset with highest criterion value has a very signal into S1, S2, systole, and diastole intervals, by emphasizing
large number of features. Kamath [73] selected mean of Teager them. To emphasize the heart signal components, envelop based
energy operator (TEO) in the time domain and frequency domain parameters such as Hilbert transform, Shannon energy, cardiac
as features set. Key characteristic of the TEO is that it models sound characteristic waveform (CSCW) and timefrequency
energy of the source that generated signal rather than the energy domain analysis such as STFT and wavelet have been presented
of the signal itself. Hence, any deviations in the regular rhythmic in the literature. After segmentation of components, classication
activity of the heart get reected in the TEO. Most of the above of PCG signal is performed by analyzing the characteristics of these
algorithms face the same challenge, requirement of a large components.
number of the feature set. Large number of feature set is required Envelope extraction based classication algorithms are able to
for diagnosis of the different types of diseases, but it results in detect fundamental heart sound components and to classify the
large computational complexity. Another challenge is due to signal as normal or abnormal. Choi and Jiang [78] compared three
variation in morphological descriptors of the heart signal envelope extraction algorithms, normalized average Shannon
with time. energy; envelope information of Hilbert transform, and the CSCW.
Since mathematical operators work in the time domain, these As shown in the results, CSCW gives a more uniform representa-
are computationally efcient and hence consume low power. tion of the fundamental components. The main challenge for the
Mathematical morphological operators have been used [74] to envelope extraction based algorithm is the selection of the thresh-
extract structural information of the ECG signals. However, com- old value. A higher value of threshold missed the S1 and S2, while
putational requirement increases as increment in order of the the lower value of threshold detects spurious components and
operators. To optimize computation requirement, Zhang and Bae inaccurate S1 and S2. To resolve this problem, Atbi et al. [79]
[8] proposed 1 dilation and 1 erosion based morphology operator proposed a two step thresholding scheme. In the rst step thresh-
sets. However, effectiveness of these algorithms depends on the old is selected to detect S1 and S2 and in the next step, to detect
selection of three structural components of the operator, shape, murmurs. Envelop extraction based algorithms are computation-
length, and amplitude. ally low complex. However, the performance of these algorithms
T wave delineation is crucial as prolongation of T wave to end depends on the morphology of the PCG signal. Furthermore, it
of the T wave is associated with ventricular pre-arrhythmicity and becomes difcult to detect S1 and S2, where murmurs are merged
sudden cardiac death. Noriega et al. [75] analyzed respiration with them.
effect on T wave. Atrial brillation (AF) is associated with an Frequency domain transformation techniques such as Fourier
increased risk of cardiovascular and coronary artery disease, transform, discrete cosine transform, and auto-regressive based
hypertension, etc. AF is typically diagnosed by analyzing irregular 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 analy- and the AC wave of SCG signal. The R-AC period varies across two
sis is more suitable for PCG signal analysis due to the diagnostic individual and also for the same person at different heart rates.
signicance of timing and frequency of PCG components. Time This study strongly suggested the cardiac events also vary in the
frequency analysis of PCG signal has been done using short time same manner. Tavakolian et al. [91] analyzed period between the R
Fourier transform (STFT) [10,80], wavelet transform [80,81]. Bou- wave of the ECG and the AO wave of SCG to analyze the myocardial
tana et al. [10] classied murmurs from PCG sound components by contractility. This period is called as pre-ejection period (PEP),
analyzing the Renyi marginal entropy of STFT coefcients. Renyi increment in the PEP indicates reduction in contract-ability of
marginal entropy remains high for murmurs and low for sound myocardial. Moreover, SCG has potential benets over ECG such as
components. While, author [80] implement the PCG analysis better specicity and sensitivity for detection of coronary artery
algorithm using STFT and wavelet on digital signal processing diseases [92].
board. In [81], rst heart sound signal is segmented into intervals
associated with cardiac cycle. Then intervals were grouped 8.2.4. Photoplethysmography
together based on similarities between their STFT coefcients. In
STFT, a trade off between time resolution and frequency resolution PPG signal contains sufcient parameters to measure heart
arises. Increment in size of time window increases the frequency rate, arterial oxygen saturation, and information related to
resolution, but reduces time resolution and vice versa. Thus, respiratory system [27,93,94]. As discussed in Section 4.4, PPG
selection of the optimal size of time window is crucial. For time measures variation in intensity of light, reected or transmitted,
frequency analysis, wavelet offers a better compromise in terms of induced by variation in the amount of blood in blood vessels.
resolution. Its main difference with STFT is that the size of the Respiration information can be extracted using three vital
window is not constant. It varies in inverse proportion to parameters: PPG amplitude, variation in SpO2, and respiratory
frequency in such a way that good time and poor frequency sinus arrhythmia [27]. Now a day, pulse oximeters (variant of PPG)
resolution obtain at high frequencies while good frequency and are being used extensively for heart monitoring [27,9395]. It
poor time resolution obtain at low frequencies. measures multiple PPG signals at different wavelengths viz., red
PCG signals have been classied using articial intelligence (660 nm) and infrared (940 nm). Pulse oximeters have been used for
algorithms such as Hidden Markov model [9] and neural network sleep apnea detection [27], pulse wave velocity calculation [93],
[82,83]. Extracted features from PCG signals using time and hypoxia detection [94], and heart rate turbulence analysis [95]. Pulse
frequency analysis tools such as wavelet are used as feature points oximeters have been developed as an in-ear sensor for cardiovascular
for these articial intelligence techniques [82,83]. Use of the monitoring [27,94]. This setup of sensor could offer three important
machine learning algorithms reduce tedious envelop analysis advantages: (1) comfortable to wear and hence, suitable for long-
and its disadvantage in case of murmurs can be avoided, but at term monitoring, (2) the tight-tting could reduce interference from
the cost of having to prepare the training dataset. To prepare the motion artifacts, and (3) robustness to conditions such as tempera-
training dataset for PCG signal, Ahlstrom et al. [84] proposed a ture or skin perfusion.
feature subset selection algorithm from features of different However, PPG signals get contaminated primarily due to
domain, including Shannon energy, wavelet, fractal dimension, ambient light, motion artifacts and other physiological process.
and recurrent quantication analysis. To extract information from the contaminated PPG signals, Mad-
PCG signal modelling is required to generate test data to hav et al. [96] proposed a multi scale principal component analysis
analyze efcacy of the developed algorithm. Modelling of PCG based algorithm. In this algorithm, noise suppression from the PPG
signals has been done using exponential damped sinusoidal model signals was achieved using wavelet decomposition and recon-
[85], matching pursuit method [86]. These methods provide struction. Selection of coefcients to reconstruct relatively clean
complete parameterization of the signal, but require a large signal was done based on two measures, energy contribution level
number of components. Whereas linear chirp signal modelling is (ECL) and Kurtosis. After reconstruction of the clean signal,
not suitable for PCG signal because components of PCG signal do principal component (PC) analysis was performed to extract
not have a linear relationship with time. To achieve better information about the respiratory system. Li and Warren [93]
accuracy, Xu et al. [87] proposed non-linear chirp signal modelling developed a sensor circuit in which photodetecters are radially
of the heart sound components. distributed around the LED to increase the sensing area. This set-
up improved the signal quality without ltering algorithm.
Whereas, Stuban and Niwayama [97] analyzed optimal corner
8.2.3. Seismocardiography frequency of low pass lter for PPG signal. Setting the corner
Seismocardiography (SCG) measures mechanical vibrations frequency to the fundamental frequency of the PPG signal resulted
produced by heart during each cardiac cycle. As discussed in in decreased noise, and consequently, decreased standard devia-
Section 4.3, SCG signal is composed of many waves. Each wave is tion. de Haan and Jeanne [98] analyzed robustness of the chromi-
associated with a particular event of the cardiac cycle. Thus, nance based algorithms to separate motion induced distortion
analysis of these waves provides diagnostic information related from rPPG signals in case of modest and vigorous motion.
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 9. Use of mobile
SCG signal can be used to detect cardiac cycle boundary, heart rate
[89], heart rate variability [90]. SCG signals have been also used to The latest generation of mobile phones (smartphones) is
obtain systolic blood pressure (SBP) [24]. It was shown that SBP increasingly used for health monitoring, due to their powerful
has the correlation with starting point of the SCG signal in the on-board computing capability, large memory, large screens and
x-axis to the midpoint of the z-axis. However, SCG has been used open operating systems that encourage application development.
for the heart monitoring purpose, but its sensitivity to motion Technical features of mobile phone including text messaging,
noise imposes limitation on its wide use. camera, internet access, inbuilt sensors, make it an appropriate
Characterization of the relation between SCG signal and ECG platform for improving health care service [99]. Wireless technol-
signal provides signicant information related to heart function- ogies, including GPRS, GSM, 3GSatelite, Wireless, Lan networks,
ality. Wick et al. [88] analyzed relation between the R wave of ECG 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 11

Mobile phones are also suitable platform to develop a heart sensors. ECG has diagnostic superiority of important CVDs as
monitoring system because of (1) the widespread adoption of compared to other portable systems. However, it has limitations
phones, (2) peoples tendency to carry their phones with them in long term monitoring of heart due to the requirement of skin
everywhere, and (3) context awareness features [99]. Furthermore, contact of electrodes and the use of gel. PCG also contains
visible representation of the health status of the patient on mobile sufcient diagnostic features, but it is vulnerable to motion noise.
encourages to be attentive for health promoting behaviour. Although, PCG has advantage over ECG in terms of easy to operate.
Mobile phones are using for long term heart monitoring at home This feature makes PCG useful in scenarios where the number of
for, both manner, on-site monitoring and off-site monitoring. Home cardiac experts is low. PPG has found its wider use for long term
monitoring supports to reduce the rates of admission to hospital for monitoring as it is more comfortable in terms of wearability than
chronic heart failure, improve the quality, reduce excessive travel other systems. But it has limited diagnostic features related to
time and reduce the cost [101103]. While long term monitoring important CVDs as it acquires signals far from the heart. SCG has
supports in early identication of deteriorations in patient condition not been used for important cardiovascular diseases. However, it
and symptom control, and timely intervention of a medical team provides some additional diagnostic parameters than those obtain
[99,104]. Smartphones based software application can help clinicians from PCG. Its higher sensitivity to motion noise than PCG and PPG
in identifying acute symptoms, decreasing unnecessary tests, to limits its wider use as portable system.
understand principles of disease diagnosis, and communication Recently, focus on at-home monitoring of heart is increasing for
facility among clinicians [99,102]. In addition, mobile applications long term monitoring, which is advantageous in cases where heart
have been used for remote coaching, reminder to patient for abnormalities are detected and suspicious to have CVDs. It leads to
appointments and health related information, public health research, increasing research in development of portable systems having
primary care, emergency care, health information for self, drug features of low power consumption, signal transmission capability,
reference, medical training, to encourage for primary care check-up, and unobtrusiveness. Computationally efcient algorithms are
etc. Mobile phone based health monitoring system have been developed that ensures low power consumption, Signal transmis-
discussed in [102]. Some of them for heart monitoring are as follows: sion capability ensures remote monitoring, and unobtrusiveness of
(1) cardiomobile is comprised of a heart and activity monitor, single the system helps in its use for long term monitoring. Power
lead ECG, GPS receiver, and programmed smartphone. The smart- consumption and user friendly connection process are main issues
phone sends ECG rate, walking speed, heart rate, elapsed distance, of signal transmission module. Advanced compression algorithms
and patient location to a secure server for real-time monitoring by for heart signals will reduce power consumption of this module.
a qualied exercise scientist. (2) Pulmonary rehabilitation is an To increase the unobtrusiveness, in case of ECG and PPG, research-
application for chronic obstructive pulmonary disease (COPD) reha- ers have proposed sensors that do not require skin contact. Use of
bilitation and self-management, developed for smartphones. (3) mVi- the cellular phones for monitoring purpose eliminates extra hard-
sum is a specialized application for cardiology communications that ware possession and hence increases user convenience. Nowadays,
monitor ECG data, alarm the user in abnormal case, and transmit cellular phones are equipped with considerable computational
data to clinician. (4) iCPR is a cardiopulmonary resuscitation (CPR) power and hence can play a crucial role for heart monitoring.
training application. This application measures the chest compres-
sion rate and gives audiovisual feedback, improving the performance
of chest compression by helping the user to achieve the correct chest Conict of interest statement
compression rate. Another smart-phone based health monitoring
system, BioSign, is reviewed in [104]. BioSign system alerts the None declared.
patient in case of abnormality. It represents the health status of the
patient as patient status index (PSI), which is calculated based on ve References
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Puneet Kumar Jain was born in Rajasthan, India, in 1988. He received his bachelor
quiescent heart phases: implications for cardiac imaging, IEEE Trans. Inf.
of technology degree in computer science and engineering from the University of
Technol. Biomed. 16 (5) (2012).
Rajasthan in 2009 and master of technology degree in information system from
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Delhi Technological University in 2011. He is currently a research scholar at Indian
waveform extraction, in: 2012 Annual International Conference of the IEEE
institute of technology Jodhpur. His research interest includes image processing,
Engineering in Medicine and Biology Society (EMBC), 2012, pp. 35533556.
biometric system and biomedical signal processing.
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[91] K. Tavakolian, G. Portacio, N. Tamddondoust, G. Jahns, B. Ngai, G. Dumont, A. Anil Kumar Tiwari received the master of technology degree in 2001 from the
Blaber, Myocardial contractility: a seismocardiography approach, in: 2012 Indian institute of technology Kharagpur and the Ph.D. degree in electronics and
Annual International Conference of the IEEE Engineering in Medicine and communication from the Indian institute of technology Kharagpur in 2005. He is
Biology Society (EMBC), 2012, pp. 38013804. currently an assistant professor at Indian institute of technology Jodhpur. His
[92] R.A. Wilson, V.S. Bamrah, J. L. Jr., M. Schwaiger, J. Morganroth, Diagnostic research interest are in Image Processing, Video Processing and Signal Processing
accuracy of seismocardiography compared with electrocardiography for the application in Bio-Medical.