1 s2.0 S0031320399000655 Main

Pattern Recognition 33 (2000) 351}373
Knowledge-based ECG interpretation: a critical review

Mahantapas Kundu, Mita Nasipuri*, Dipak Kumar Basu
Department of Computer Science & Engineering, Jadavpur University, Calcutta 700 032, India
Received 16 June 1998; accepted 10 March 1999
Abstract
This work presents a brief review of some selected knowledge-based approaches to electrocardiographic (ECG) pattern
interpretation for diagnosing various malfunctions of the human heart. The knowledge-based approaches discussed here
include modeling an ECG pattern through an AND/OR graph, a rule-based approach and a procedural semantic
network (PSN) based approach for ECG interpretation. However, certain syntactic approaches to ECG interpretation
are also covered, considering their precursory roles to knowledge-based ECG interpretation. A fuzzy-logic-based
approach is included in the discussion to show how imprecision can be dealt with in modeling cardiological knowledge.
A domain-dependent control algorithm is discussed to show how the production level parallelism can be exploited to
reduce the length of the match}resolve}act cycle of a rule based ECG interpretation system. The review also contains
a brief description of some recent applications of connectionist approaches to ECG interpretation. This discussion "nally
ends with a comparative assessment of performances of all the above-mentioned knowledge-based approaches to ECG
interpretation and some hints about the future directions of work in this "eld. 2000 Pattern Recognition Society.
Published by Elsevier Science Ltd. All rights reserved.
Keywords: Automated ECG interpretation; Knowledge-based system; AND/OR graph; Procedural semantic network; Fuzzy logic;
Connectionist approach; Arti"cial neural network
1. Introduction
The Electrocardiogram (ECG) [1}3], as shown in
Fig. 1(a) and (b), is the record of variation of bio-electric
potential with respect to time as the human heart beats.
Interpretation of ECG patterns is needed for diagnosing
malfunctions of the human heart. Ventricular heart rate
is the most common item of information among those
which can be extracted from the ECG tracing of the
human heart by measuring the time distance between
two successive R peaks shown in Fig. 1(a). It is required
for detection of ventricular "brillation and other life-
threatening arrhythmias or abnormal cardiac rhythms.
The need for automated ECGinterpretation was prim-
arily felt to ensure continuous and constant observation
of the patients' ECG tracings on the oscilloscope at the
*Corresponding author.
E-mail address: nasipuri@giascl01.vsnl.net.in (M. Nasipuri)
Intensive Coronary Care Unit (ICCU). For the patients,
mostly su!ering from myocardial infarction, at the
ICCU, the sooner is the detection of arrhythmias, the
greater is the chance of recovery [4]. This is so because it
was observed that life-threatening arrhythmias were usu-
ally preceded by less-severe premonitory arrhythmias [5]
and by timely detection and proper therapeutic treat-
ment of the latter, the occurrences of the former might be
avoided. The technique of ECG interpretation followed
at the ICCU in early 1960s was semiautomatic. It was
performed through continuous visual observation of the
ECG tracing on the oscilloscope alongwith an automatic
heart rate alarm [6].
The importance of automated ECG interpretation was
also felt in analyzing the prerecorded 24 h ECG tracing
from the ambulatory patient for investigation of possible
cardiac events, related to various physical activities and
life situations [7].
Usually, computer-based ECG interpretation per-
forms classi"cation of ECG patterns after extracting ne-
cessary wave features from the preprocessed digitized
0031-3203/00/$20.00 2000 Pattern Recognition Society. Published by Elsevier Science Ltd. All rights reserved.
PII: S 0 0 3 1 - 3 2 0 3 ( 9 9 ) 0 0 0 6 5 - 5
Fig. 1. (a) The pattern of a typical ECG segment. (b) Four di!erent chambers of the human heart. (c) Necessary wave features for
classi"cation of arrhythmia patterns.
ECG patterns. Since 1960s a great deal of research has so
far been done in this "eld [6,8}63,86}106] and knowl-
edge-based ECG interpretation [64}71] has evolved as
an o!shoot of it. The major objective of knowledge-based
ECG interpretation is to achieve precise and accurate
diagnosis through closely modeling the physician's abil-
ity to diagnose ECGs by application of various deductive
approaches from the "eld of knowledge based comput-
ing. A typical block diagram of a knowledge-based ECG
interpretation system is shown in Fig. 2. In this system,
all the domain knowledge, acquired in consultation with
the experts in the "eld of cardiology, is logically encap-
sulated in a separate module, called the knowledge base
(KB). The KB is full of knowledge pieces which are
selectively applied to interpret ECG patterns. How best
this interpretation can be made with selection and sub-
sequent application of knowledge pieces is determined by
a control program, also known as an inference engine.
The task of the inference engine or control program is
viewed as a search process seeking a proper sequence of
knowledge pieces whose application can interpret the
input ECG pattern or classify it into one of the normal
and the abnormal ECG pattern classes. So, with the
development of the knowledge-based ECG interpreta-
tion system, two things become possible. Firstly, addition
of any knowledge, that may be acquired for better diag-
nosis of ECGs in future, can be performed without re-
compiling the control program, which greatly simpli"es
the construction and maintenance of the system. Second-
ly, due to seggregation of the search process in the form
of a control program, heuristics or domain dependent
task speci"c information can easily be applied with the
control program to make the search for wave features
and pattern classes more e$cient.
352 M. Kundu et al. / Pattern Recognition 33 (2000) 351}373
Fig. 2. The block diagram of a typical knowledge-based system for ECG interpretation.
At this point, one should not presume that the other
approaches to computerized ECG interpretation, which
do not fall in the category of knowledge-based ones, do
not require the knowledge about the structural descrip-
tion of the ECG pattern. They do require the knowledge
about various medically meaningful geometric features of
the ECG pattern. But, unlike the knowledge-based ap-
proaches, that knowledge is not easily separable from the
description of the task-dependent ad hoc procedures,
which constitute the other category of methods for
computerized ECG interpretation, called procedural ap-
proaches [72].
Under the procedural approaches to ECG inter-
pretation, searches for automatic extraction and in-
terpretation of useful wave features become sometimes
exhaustive in nature [8] and there is no provision for
application of an heuristic that may reduce the search
for "ts.
In late 1970s, several research attempts [9}11,17,
29,42,43,46,47,61] were made to encode ECG patterns
as strings of symbols, representing various primitive geo-
metric patterns, and to develop syntaxes of normal and
abnormal ECGs with formal grammars. Because of easy
availability of several algorithms for piecewise linear ap-
proximation of discrete functions [9,11,16], the straight
line becomes a natural choice for the primitive geometric
patterns that constitute complex ECG patterns. Depend-
ing on line lengths and slope values, straight lines are
encoded into di!erent symbols. Context-free grammars
[11,61] and regular grammars [29] are used for ECG
pattern classi"cation.
Extraction of geometric features, such as straight lines
and parabolas, from ECG patterns require "nding the
best-"t curve for a large portion of an ECG pattern by
running a number of curve-"tting routines. It involves
high cost of extensive search. The search for a possible
primitive can be focussed to a suitable portion of an ECG
pattern by utilizing the structural knowledge of the ECG
pattern, encoded in the production rule which has al-
ready been selected for derivation. This idea was "rst
introduced for structural pattern recognition of carotid
pulse waves by developing a general Waveform Parsing
System (WAPSYS) [64], and then extended with the best
"rst state space search algorithm for the linguistic analy-
sis of waveforms [73] in general and "nally applied for
recognition of ECG patterns [65]. The restriction, im-
posed by traditional parsing method for strict left to right
processing of the input string, was also relaxed in the
WAPSYS to allow the detection of more readily recog-
nizable portions of the wave features earlier. Since such
features are widely separated in most of the waves, any
attempt for early detection of these features may make
the task of identi"cation of ambiguous parts of the wave-
form easy. The general waveform parsing system fol-
lowed a top-down approach.
One major di$culty of applying traditional parsing
methods for ECG interpretation is that the parsing
methods follow either a top-down or a bottom-up ap-
proach strictly, but one such approach alone cannot
perform uniformly well over all portions of the ECG
pattern. The data directed bottom-up approach works
well over those portions of the ECG pattern where con-
centration of di!erent geometric structures occurs,
whereas the model-directed top-down approach works
well over the other portions where possibilities for hy-
pothesizing the structures are very few. In order to get the
bene"ts of these two approaches together, the CFG,
representing an ECG pattern class, is converted into an
AND/OR graph and the problem of ECG pattern inter-
pretation is thereby reduced to an AND/OR graph
search problem. Kanal applied a best "rst state-space
search method, known as SSSH [65,73], from the "eld of
Arti"cial Intelligence (AI) for ECGpattern interpretation
through an AND/OR graph.
The method introduced by Kanal is based on the
morphological waveform knowledge of ECG tracings
only. But more accurate interpretation of the ECG pat-
tern is possible by applying the physiological event
knowledge of the cardiac conduction system together
with the morphological waveform knowledge. This is
M. Kundu et al. / Pattern Recognition 33 (2000) 351}373 353
achieved in the Causal Arrhythmia Analysis (CAA) Sys-
tem [66}68], implemented with the knowledge repres-
entation language called Procedural Semantic Networks
(PSN). In the CAA system a frame-type representation of
semantic network is used to maintain a strati"ed know-
ledge base that contains knowledge about the waveform
of ECG signals, knowledge about the physiology of
rhythmdisorders, and their interrelationships. Projection
links are introduced to describe the concept-to-concept
relationships accross di!erent KBs.
Fast detection of arrhythmias is necessary for the pa-
tients in the ICCU where round-the-clock monitoring
of ECGs is performed. In view of this, a rule-based
approach [70,71] is developed for real-time interpreta-
tion of ECG pattern classes by using &if-then' form of
rules and facts are prepared with extracted features from
the input ECG pattern. It uses modus ponens (MP) as
rule of inference from two valued "rst order predicate
logic (FOPL). A control program is also there to use the
rules and facts to determine the class membership of the
ECG pattern. A block diagram of the system has already
been shown in Fig. 2.
The above methods assume that knowledge of ECG
patterns is fully precise and that variation in the input
pattern always follows the pattern description stored in
the KB. But, in practice, some pattern may slightly di!er
fromwhat is described in the KB or the knowledge that is
acquired from the physicans may not be quite precise.
In such situations, conventionally followed two valued
logic, used in all the previously described methods, can-
not provide satisfactory solution, i.e. it cannot lead to
rational decisions in an environment of uncertainty and
imprecision unlike what a human physician can do. Gen-
eralized Modus Ponens (GMP) [74], a rule of inference
taken from fuzzy logic, is shown to have the capability of
detecting "ner variations in ECG patterns without mak-
ing any augmentation of the existing KB. The previously
described rule-based system has been modi"ed for this
purpose in Refs. [75}78].
In another separate attempt [69] the control algo-
rithmfor the rule-based system is modi"ed to take care of
production level parallelism to reduce the length of the
match}resolve}act cycle of the system. This opens up
possibilities for the development of cost e!ective multi-
patient arrhythmia recognition systems.
All the knowledge based approaches to ECG inter-
pretation, discussed so far, are in general featured by
a high level of abstraction and macroscopic view of
human reasoning. As an alternative to that, low level,
microscopic models of biological networks, controlling
human reasoning, are also recently being employed for
closer modeling of the cardiologists' diagnostic ability
through connectionist or arti"cial neural networks
(ANNs) based approaches [79]. Connectionist appro-
aches are mainly featured by learning ability, massive
parallelism and fault tolerance. Adaptive resonance the-
ory (ART) networks and multi layer perceptrons (MLPs),
two ANN models, have been successfully applied for
extraction of wave features [80,81] and recognition of
fatal arrhythmias (ventricular tachycardia and ventri-
cular "brillation) [62,81], respectively, from noisy time
varying ECG patterns.
The major objectives of this review work are "rstly
to present a brief account of the state-of-the-art of
knowledge based ECG interpretation techniques with a
comparative assessment of their performances, second-
ly to identify the outstanding problems that still cre-
ating hinderance to the more satisfactory functioning
of computer based ECG interpretation techniques,
reported in the recent time, and "nally to indicate pos-
sible scope of further work for improvement of their
performances.
2. ECG patterns and cardiac disorders
The electrocardiogram (ECG) is the record of vari-
ation of the bioelectric potential with respect to time as
the human heart beats. Fig. 1(a) shows the pattern of
a typical ECG segment, recorded under the normal
condition of the human heart. In this "gure, various
points of de#exions, which are marked as P, Q, R, S
and T depending on the curvature around each point,
are called waves and correspond to actions of di!erent
muscular chambers of the human heart, shown in
Fig. 1(b). The P wave corresponds to the contraction of
the atria, i.e. the upper heart chambers. The forces of
contraction in the atria are generated due to an excita-
tion initiated at the SA node located high at the right
atria. This excitation gradually spreads out from the atria
to ventricles through the A-V node, the his-bundle and
purkinje "bers respectively, causing contraction of the
ventricles. This contraction and the relaxation of atria
correspond to the R wave alongwith the Q and S waves
that form the QRS complex, appearing as a spike in the
diagram. Occurring after the QRS complex, the T wave
corresponds to relaxation in the ventricles. A single beat
of the human heart starts with an atrial contraction and
ends with a ventricular relaxation. The pumping action
of the human heart is maintained with continuous gen-
eration of such heart beats one after another till one's
death.
Thus the ECG pattern under the normal condition
of the human heart shows a periodic nature with R
waves occurring at regular intervals of time. Since
ECG patterns get distorted with rhythm disorders in
the human heart, computerized ECG interpretation
requires extraction and analysis of di!erent wave fea-
tures, like the shape and size of the QRS complex, the
number of P waves in an ECG cycle and some other
features, shown in Fig. 1(c) for classi"cation of ECG
patterns.
Fig. 3. The AND/OR graph representing a typical ECG pattern.
3. Representation of ECG patterns and cardiological
knowledge
For medical diagnosis of ECG patterns, they are usually
represented in terms of various medically de"ned wave
features, like P wave, P-R duration, QRS complex, S-T
segment etc., which in turn are represented with simple
geometric structures like straight line, parabolas and peaks
[9,11,16]. The cardiological knowledge that is needed for
interpreting ECGpatterns can be categorized as morpholo-
gical waveformknowledge of ECGtracings and the Physio-
logical event knowledge of the cardiac conduction system.
For usual purposes, the morphological waveform
knowledge of ECG tracings is su$cient for quick detec-
tion of arrhythmias. Various knowledge-based ECG in-
terpretation approaches mainly di!er from each other in
the way the cardiological knowledge is represented. De-
pending on this their performances also vary.
3.1. AND/OR graph representation of ECG patterns
In this approach, an ECGpattern with all its hierarchi-
cally decomposed components is represented through an
AND/OR graph [65,73], in which nodes are suitably
labeled with names of various pattern components. Each
node in this graph represents a component pattern except
the start node, a specially designated node that represents
the entire pattern. It is like that each symbol, nonter-
minal or terminal, in a context free grammar (CFG)
representing a class of ECG patterns, stands for a com-
ponent pattern except the start symbol which represents
the entire pattern. As a production rule in the CFG
indicates how a pattern or subpattern, represented by the
nonterminal symbol in the left-hand side of the rule, can
be decomposed into component patterns, a node in the
AND/OR graph does the same, being connected to
its successors in the graph through directed arcs. Fig. 3
shows an AND/OR graph that corresponds to a CFG
representing a class of typical ECG patterns.
Some nodes which are pointed to by hyper-arcs in the
AND/OR graph are called AND successors, and the
others which are pointed to by normal arcs are called OR
successors. The AND successors of a node are labeled
with the names of the structural components of a pattern
or subpattern denoted by the node. The OR successors of
a node are labeled with the names of various alternative
structural descriptions of a pattern or subpattern, like
various alternative production rules of a CFG, which
involve identical nonterminal symbols to their left hand
sides. In Fig. 3, node 1 represents an entire ECG pattern
which is constituted with a R wave denoted by node 2
and a train of ECG patterns denoted by node 3. A train
of ECG patterns is in turn constituted with an ECG cycle
(node 7) starting froma R wave and ending at a Q peak of
the next cycle, and the end portion of the train (node 8).
The end portion of the train may either end at a sample
point denoted by node 10 or continue with the rest
portion of the said train, denoted by node 51, depending
on the length of the ECG pattern. The tip nodes in this
graph represent various pattern primitives and act as
the terminal symbols of the pattern grammar. The
pattern primitives for the ECG pattern are de"ned as line
segments or parabolic segments "tted under certain
constraints, such as slope limits, curvature limits, noise
limits and segment length limits, which are stored as
attributes of the nodes in the graph. The numeric labels
on the edges, entering into the node of the AND/OR
graph in Fig. 3, indicate the order in which the geometric
structures represented by the nodes are to be searched
in the input pattern. Thus, the numeric labels help in
making non-left-to-right processing of the input pattern
possible.
3.2. Rule-based representation of cardiological knowledge
For interpretation of arrhythmic ECG patterns,
the cardiological knowledge based on the extracted wave
features from the input ECGs is to be stored in the
computer. The extracted wave features which form
the basis of the caridological knowledge are each de-
scribed through a simple sentence or proposition which
can be either true or false depending on the input ECG
pattern. For example, an ECG instance with an average
heart rate of 100 beats per minute or above is referred as
high rate in cardiology. This wave feature can be sym-
bolically denoted by a predicate, HIGH-HEART-RATE,
which can be either true or false depending on the time
durations of the extracted R-R intervals. This is all about
simple propositions. For representation of compound
propositions, logical connectives like &and', &or', &not', are
used with such simple propositions. Each unit of the
cardiological knowledge, used for analysing arrhythmia
patterns on the basis of extracted wave features, is repre-
sented in the form of an &if-then rule' or implication as
described in [70]. For example, Sinus tachycardia, a class
of arrhythmia, occurs if the average heart rate in the
input ECG is 100 beats per minute or more } this know-
ledge is represented as
if (the average heart rate is high)
then (the diagnosis is sinus-tachycardia)
or
HIGH-HEART-RATENSINUS-TACHYCARDIA
In this rule or implicational formula, the if-part is
called antecedent or precondition and the then-part con-
sequent or conclusion. The above implicational formula
is equivalent to the following:
&(HIGH-HEART-RATE)
R(SINUS-TACHYCARDIA).
3.3. Representation of domain knowledge by PSN
A procedural semantic network (PSN) knowledge base
consists of objects, which can be tokens, classes, links,
relations, and programs. A token represents a particular
entity like a QRS pattern, a T wave, a R-R interval,
1 second of time etc. Tokens are interrelated through
links representing binary relationships between entities.
A class represents certain generic concepts like the class
of numbers, the class of QRS patterns, the class of R-R
intervals, etc. Each token is an instance of at least one
class and each link an instance of at least one relation.
Fig. 4 shows two tokens as 1 and 60, classes as R-R-
duration, Seconds, and beats-per-minute, a relation as
Heart-rate-of and a link relating 1 and 60. It also shows
INSTANCE-OF relationship between 1 and R-R dura-
tion, 1 and second, 60 and Beats-per-minute, link 1-60
and Heart-rate-of.
The semantics or the meaning of a class is de"ned by
attaching four programs to each class, which specify
respectively how to insert, remove and fetch instances of
the class, and how to test whether an object is an instance
of the class. Likewise, each relation has four associated
programs that specify how to insert or remove instance
links, how to fetch all the objects in the range of the
relation associated with a particular instance of the do-
main, and how to test if two objects are interrelated
through an instance of the relation. This approach is
more modular than what was generally followed by treat-
ing the network as a data structure and providing a gen-
eral global interpreter to query, modify and search the
structure.
Fig. 4. Representation of the relation Heart-rate-of.
Fig. 5. (a) Representation of a QRST-COMPOSITE-SHAPE. (b) IS-A hierarchy of QRST-COMPOSITE-SHAPE. (c) The strati"ed
knowledge base of the CAA system.
In order to design a structured representation of a
large knowledge base, PSN o!ers three primitive rela-
tions viz. INSTANCE-OF, PART-OF, and IS-A. It has
been already shown that INSTANCE-OF links between
tokens and classes that constitute their types. In PSN, the
INSTANCE-OF relation is used to relate all objects,
including tokens, classes, links, relations and programs,
to their respective types.
The PART-OF relation is based on the organizational
principle of Aggregation /Decomposition for structuring
a PSN knowledge base. Each concept, a class or relation,
can be viewed as an aggregate of some simpler concepts.
For example, how a QRST-composite shape can be con-
ceptualized as a combination of its di!erent structural
components, is illustrated by the di!erent slots, labeled
with the names of corresponding (structural) components
in its frame description, shown in Fig. 5(a).
The IS-A relation is based on the organizational prin-
ciple of Specialization/Generalization for structuring a
PSN knowledge base. On this principle, classes can be
split into subclasses to generate a taxonomy of classes,
known as an IS-A hierarchy. The IS-A relation relates
a subclass to its class and is graphically represented
by a thick arrow with double edges. For example, the
class QRST-composite-shape can have "ve subclasses,
as shown in Fig. 5(b). A sub-class, which is related to a
class by an IS-A relation, can inherit all the properties or
slots from the class due to property of inheritance. This is
why a subclass is de"ned by imposing certain constraints
on the ranges of values of the inherited slots and/or
de"ning certain additional slots for it only. A class can at
a time be related with more than one class by IS-A and
INSTANCE-OF relations.
The CAA system [66}68] using PSN knowledge bases
has to work for recognition purposes. In order to guide
the search process, when certain input pattern fails to
match with a given class in a PSN knowledge base,
various exception conditions, depending on the nature of
failure, are associated with a class de"nition, and sim-
ilarity links are used to associate the other classes to be
tried next after an exception occurs.
The physiological knowledge base, in the CAA system,
represents the knowledge to explain abnormalities in the
cardiac conduction system and interpret rhythm disorder
as a causal phenomenon in this subdomain. Four basic
phases or events of the cardiac conduction system, which
are considered as the basic building blocks of the physio-
logical knowledge base, are identi"ed as depolarization,
under-repolarization, partial-repolarization, and full-
repolarization. By using PART-OF relation, the basic
phase events are aggregated to form di!erent cardiac
cycles, as shown in Fig. 5(c). Likewise the cardiac cycles
are aggregated to form di!erent cardiac activities, activ-
ities to di!erent beats and beats to di!erent beat patterns.
Thus a complete beat is conceptualized to consist of
a SA-node cycle, an atrium activity, an AV-node activity,
a ventricular activity and "nally, a beat pattern is concep-
tualized to consist of several such beats. In order to
represent the causal relationships among the basic events
of a single cycle and among the events of di!erent cycles,
causal links, as shown in Fig. 5(c), are used. Arrow-
headed dotted lines in the "gure denote transfer type
links. An event, directed by a transfer type link, occurs
when the causative event, shown at the arrow tale, com-
pletes in normal course. Initiation type links are shown
with arrow-headed double lines in the Fig. 5(c). Each
such link is used when the causative event, due to a given
subject, triggers a new event of another subject.
3.4. Representation of cardiological knowledge using
fuzzy logic
Fuzzy logic is based on the concept of fuzzy sets [74].
Fuzzy sets, in contrast to classical sets, have greater
#exibility to capture faithfully various aspects of incom-
pleteness and imperfection in a situation. For example,
a classical set A, de"ning an arrhythmia class Sinus
tachycardia, includes all ECG instances with the average
heart rate 100 beats per minute or above by assigning a
membership value 1 to each, and excludes all other with
the average heart rate below 100 beats per minute by
assigning a membership value 0 to each. So the member-
ship function, denoted by
, for a classical set A can

have either 0 or 1 value for any element, u, of its do-
main of discourse denoted by ;. This is expressed as
(u)3+0,1,. The de"nition of Sinus tachycardia as a

classical set is very strict in the sense that it cannot
express the impreciseness of the concept that is felt if
some one hesitates to classify an instance of ECG pattern
with the average heart rate not exactly but nearing 100
beats per minutes as a very clear case of Sinus tachy-
cardia. In order to accommodate this "ne imprecision
associated with the de"nition of Sinus tachycardia, the
membership value should be allowed to vary smoothly in
[0, 1] through a suitably drawn membership function. As
a result, the said instance of ECG pattern can be "tted
into the de"nition of Sinus tachycardia but its member-
ship value will be something below unity. This is possible
by de"ning the concept Sinus tachycardia as a fuzzy set
A where
A
(u) is the degree of belongingness of u to A or
the degree of possessing some imprecise property repre-
sented by u and
A
(u)3[0, 1].
A
(u) may also be viewed as
the extent to which the concept associated with A must
be stretched to "t u into it. In fuzzy logic, a fuzzy rela-
tion is also de"ned in the same way as the fuzzy set is
de"ned. If A represents an n-ary fuzzy relation in
;";1;;2;2;;
L
, then the membership function
A
is expressed as
A
(u)3 [0, 1], where u3;.
3.4.1. Cardiological propositions in fuzzy logic
The meaning of a proposition or simple sentence in
fuzzy logic, in contrast to that of a proposition in two-
valued logic*which can be either true or false*is ex-
pressed by equating the value of a linguistic variable to
a fuzzy relation, both of which are implicit in the proposi-
tion. For example, in the proposition àverage heart rate
of ECG cycle is higha, àverage heart rate of ECG cyclea
is a linguistic variable and `higha is a fuzzy relation. In
canonical form, this can be expressed as
average-heart-rate (ECG-cycle) is HIGH
Like a fuzzy set or relation, which can have a member-
ship function, a linguistic variable can have a possibility
distribution de"ned as the set of possible values of the
variable with the assumption that possibility is a matter
of degree. The values of a linguistic variable in a proposi-
tion are constrained by equating its individual possibility
distribution to the fuzzy relation in the proposition. Thus
the fuzzy relation in a proposition plays the role of an
elastic constraint on the variable that is implicit in the
natural language proposition. The possibility distribu-
tion of the linguistic variable &average-heart-rate(ECG-
cycle)' can be expressed as follows:
Poss+average-heart-rate(ECG-cycle),
"
HIGH
(u), u3;,
where ;is the domain of discourse,
HIGH
is the member-
ship function of HIGH and
HIGH
(u) is the grade of
Fig. 6. Membership functions of di!erent linguistic values of
average-heart-rate.
membership of u in HIGH or equivalently the degree to
which u, a numerical value of average-heart-rate, satis"es
the constraint induced by the relation HIGH. In order to
indicate the fuzzy relation in the above proposition, bold-
faced capital letters are used. Fig. 6 depicts the function
HIGH
which is plotted on the basis of clinical experiences.
The lingusitic variable average-heart-rate(ECG-cycle)
may also have other values like not-HIGH, more-or-less-
HIGH and very-HIGH. Out of all possible values of a
linguistic variable, one like HIGH is called a primary
term since the other values of the linguistic variable can
be generated from it as follows, when nothing is speci"-
cally known about them.
'''''
"(
'''`''
,
`'`
"(
'''`''
),
"'
"1!
'''`''
.
Terms like &more-or-less', &very', &not' are called modi"ers
of the primary term. The fuzzy relation more-or-less-
HIGH is called a dilation of HIGH since the dilation
tends to increase the degree of membership of all partial
members of HIGH by spreading out the characteristic
membership function curve of more-or-less-HIGH. The
opposite of dilation is concentration and it is, in this case,
very-HIGH. It tends to decrease the degree of member-
ship of all partial members of HIGH by concentrating
the characteristic membership function curve of very-
HIGH. The fuzzy relation not-HIGH is called antonym
of HIGH. Fuzzi"cation of facts in the system [71] is
performed by comparing numeric values of the extracted
ECG features against certain thresholds and assigning
appropriate linguistic values to them. For example, a P-R
duration having a value 0.185 to 0.199 s is fuzzi"ed as
(P-R duration is more-or-less-HIGH). Details of these
thresholds for fuzzi"cation can be found in [71,75].
The example, discussed above, shows how the work
[71,75}78] attempts to model human intuition relating
to cardiology by heuristically estimating possibility dis-
tributions for linguistic values of the variables concerning
di!erent concepts of caridology. Sentences like ìf aver-
age heart rate of ECG cycle is high then diagnosis is
Sinus tachycardiaa, which are used to express various
rules for cardiological diagnosis, can each be viewed as
a combination of two simple propositions connected
through an implication. Such propositions expressing
rules are called conditional propositions. The said condi-
tional proposition, in canonical form, is expressed in
either of the following forms:
(diagnosis (ECG-cycle) is SINUS-TACHYCARDIA)
If (average-heart-rate (ECG-cycle) is HIGH)
or
(average-heart-rate (ECG-cycle) is HIGH)
N(diagnosis (ECG-cycle) is
SINUS-TACHYCARDIA)
In general, a conditional proposition in fuzzy logic, is
expressed as (X is A) N(> is B) where X and > repres-
ent two linguistic variables, A and B represent two fuzzy
sets. Each such implication in fuzzy logic induces a condi-
tional possibility distribution of the linguistic variable
> given the possibility distribution of the linguistic
variable X, written as
7'6
. The fuzzy relation, which
corresponds to the conditional possibility distribution
function
7'6
, is computed as follows
7'6
(u, v)"
A
B
(u, v)"minimum(1,1!
A
(u)#
B
(v))
where u3;, v3<, ;is the universe of discourse of A and
< the universe of discourse of B.
The rules used in the rulebase of the fuzzy-logic-based
system for ECG interpretation are of three types, the
purely fuzzy rules with fuzzy propositions in both if-part
and then-part, the non-fuzzy rules with non-fuzzy prop-
ositions in both if-part and then-part, and mixed cat-
egory rules with fuzzy and non-fuzzy propositions. Three
practical rules from the three respective categories are
shown below:
(i) If (QRS duration is ABNORMAL) then (QRS com-
plex is ABNORMAL).
(ii) If (R-R duration is 70% or more premature) then
(diagnosis is R-on-T).
(iii) If (current ECG cycle is VPB) (last ECG cycle is
VPB) (R-R duration is nearly equal to P-P dura-
tion) (average heart rate is 150 beats/min or more)
then (diagnosis is ventricular-tachycardia).
Out of these rules of three categories, only those of
purely fuzzy category generate fuzzy inferences.
4. Diagnosis of ECG patterns
Diagnosis of ECG patterns, under knowledge-based
approaches, is performed by application of the stored
knowledge in interpretation of the input ECG patterns.
This is called inference process. A control program that
guides how the stored pieces of the knowledge can be
selectively applied for a step-by-step interpretation of an
input ECG pattern is called Control system. The logical
connections of a control system to other components of
a knowledge based ECG interpretation system are
shown in Fig. 2. Keeping in view of one speci"c type of
knowledge representation technique, one speci"c infer-
ence method is designed.
4.1. Control strategy for the WAPSYS
In order to determine the curve-"t constraints required
for completing the de"nitions of various pattern primi-
tives, Waveform Parsing System (WAPSYS) [64] "rst
allows the user to try various curve "tters on some
sample ECGs. A testing module of the system is then
used to automatically identify the same curve "t con-
straints on other samples to check the tentative grammer.
In order to recognize an input ECG, probable candidates
for a prominent waveformfeature are "rst located in it by
WAPSYS. Then the parsing process starts, being guided
by the knowledge of the ECG pattern stored through an
AND/OR graph. Smaller the number labeling an edge,
higher the prominence of the node at the edge-tip. As the
AND/OR graph of Fig. 3 shows, the upslope (UPSLOP)
of a R wave (1R2) in an ECG pattern is the most promin-
ent waveform feature.
When the existence of a waveform feature, primitive or
compound, is ensured in an interval of the input pattern,
the corresponding node in the AND/OR graph is con-
"rmed. Expansion of a node is done in view of con"rming
its descendants according to their priorities. In order to
accomplish the task of expanding or con"rming a node,
WAPSYS calls a user supplied semantic routine, meant
for purposes as calling curve "t constraints, recording
peak measurements or noting intervals. The routine is
also meant for making further measurements such as
adding intervals together until the interval for a complete
ECG cycle is obtained. The WAPSYS, after automati-
cally locating the steepest upslope in the input ECG
pattern, con"rms node 11 and expands node 12 to locate
the large negative down slope of the R wave in a speci"ed
interval adjacent to right of the upslope and on recogni-
tion of the large negative down slope, node 12 is con-
"rmed. With this, node 2 is also con"rmed and a R wave
in the input ECG is located. The WAPSYS then expands
nodes 3, 7 and 2 in order. With the con"rmation of node
2, the next R wave in the wave train is located, and the
period, rate and baseline drift of the "rst cycle between
R waves are computed. In order to parse the wave seg-
ment between the two R waves in the input pattern, the
WAPSYS then expands node 9. Con"rmation of node
9 requires con"rmation of all waves and intervals in the
cycle. Nodes 8 and 51 are expanded to locate the next
R wave in the input wave train. When no part of the
input wave train is left to be parsed, node 10 is con"rmed.
4.2. Control strategy for the rule based system
A rule-based expert system is formed by representing
the domain knowledge in the way described in Section
3.2. The expert system [70] that interprets ECG patterns
applies the domain knowledge on the extracted wave
features to draw an inference. The rule of inference,
followed by the expert system, is Modus Ponens [82]. It
works as follows:
Fact: HIGH-HEART-RATE
Rule: HIGH-HEART-RATENSINUS-
TACHYCARDIA
Inference: SINUS-TACHYCARDIA
The above example shows that under Modus Ponens
[70], a rule can be applied only when its precondition can
be satis"ed with any of the facts about the input ECG
pattern. With a rule application, the consequent of the
rule is considered as the inference. Classi"cation of an
input ECG pattern into one of the arrhythmia classes
requires several such rule applications, which form a
chain of inferences.
All facts prepared from the input ECG pattern are
conjunctively connected to form the fact expression that
is stored in the fact base shown in Fig. 2. An inference,
drawn through a rule application, is also stored in the
fact base to be used as a new fact in subsequent rule
applications, resulting into a chain of inferences neces-
sary for class"cation of the input ECG pattern.
The rule, cited in the above example, is of simplest
type. Let us consider the following three practical rules to
observe how these rules can be applied by the control
system to form a chain of inferences with an input ECG
pattern.
1. (i) If (QRS amplitude criteria is not satis"ed) then
(QRS complex is abnormal).
(ii) If (QRS duration criteria is not satis"ed) then (QRS
complex is abnormal).
2. If (R-R duration is 20% or more premature) (QRS
complex is abnormal) then (diagnosis is VPB)
3. If (a VPB occurs in current cycle) (another VPB
occurred in last cycle) (average heart rate is as high
as 150 beats/min) then (diagnosis is ventricular-
tachycardia).
As illustrated in Fig. 7, the rule number 1(i) or 1(ii) can
be directly applied with the extracted fact that &QRS
Fig. 7. The chain of inferences using Rule nos. 1 and 2.
duration or amplitude criteria is not satis"ed' to assert
a new fact that &QRS complex is abnormal'. With this
asserted fact and another extracted fact that &R-R dura-
tion is premature', rule number 2 can be applied to assert
another new fact that &current ECG cycle is VPB'. With
this and two more facts that &another VPB occurred in
last cycle' and &average heart rate is 150 beats per minute',
the rule number 3 can be applied to complete the chain of
inferences that results into the "nal conclusion that &diag-
nosis is ventricular-tachycardia'.
A selected rule is applied over the factbase under the
supervision of the control system by asserting its con-
clusion. The control system completes inference about
the current ECG cycle after classifying it into one of the
disjunctive ECG pattern classes in the goal expression.
Each time all the facts about an ECG cycle arrive at the
factbase the control system is activated for drawing in-
ferences. Also the diagnosis of one cycle is completed
before all the facts about the next cycle arrive at the
factbase. This makes it feasible to utilize the result of
diagnosis of an earlier cycle in inferring about the next
cycle.
4.3. Control strategy for arrhythmia recognition under
the CAA system
The control strategy for arrhythmia recognition de-
pends on three major activites of the control system, viz.,
peak detection, waveform analysis and event analysis
[66}68].
First, peaks in the input ECG are detected by applica-
tion of a syntactic approach introduced by Horowitz [9].
It requires piecewise linearization of the ECG pattern by
the split-and-merge technique. The piecewise linearized
pattern is encoded into a string of symbols to be parsed
by a grammar, specially designed to recognize and meas-
ure the attributes of all peak patterns in the input ECG.
After all peaks are detected and measured, some con-
secutive peaks, with high amplitudes and steep slopes, are
chosen as the candidate wave pattern for analysis. Recog-
nition of wave shapes from the candidate pattern starts
by hypothesizing the most generic shape class and grad-
ually specializing it into more speci"c classes along the
IS-A class hierarchy described in the morphological KB.
Con"rmation of a class hypothesis requires satisfying all
slot constraints in the class de"nition by the morphologi-
cal features of the candidate wave patterns. Thus the
wave shape recognition strategy, which works through
gradually specializing class hypotheses, also requires ag-
gregation of features of the candidate pattern for hypoth-
esis con"rmation. If an attempt to con"rm a hypothesis
fails, an alternative hypothesis is chosen with the help of
similarity links.
Recognition of a candidate wave pattern is com-
pleted with the con"rmation of the hypothesized classes
for it. The recognized wave classes are projected into
the physiological event domain to form their corre-
sponding event hypothesis. For example, a candidate
wave pattern recognised as STANDARD-QRST-COM-
POSITE-SHAPE with STANDARD-QRS-COM-
PLEX-SHAPE and NORMAL-T-WAVE-SHAPE, can
be projected into the event domain as illustrated earlier
in Fig. 5(c). This generates the set of basic event hypothe-
ses, which consists of the depolarization and the partial
repolarization phase events of the left ventricle. In order
to perform event analysis with the basic events hypothe-
ses, the causal links which are associated with the basic
events are used to generate expectations for other events.
All these events are gradually aggregated to hypothesize
beat event class depending on the projected and expected
events. Thus, from each candidate wave pattern (also
known as a set of signal tokens), a beat event class is
hypothesized.
Since several beat patterns constitute a periodic ar-
rhythmia pattern, its repetitive behaviour is de"ned by
the recursive de"nition of beat-pattern frames as shown
in Fig. 8. In order to recognize an arrhythmia in the input
ECG pattern, global hypothesis about an arrhythmia
class is to be generated "rst.
The hypothesis projection method described above is
used to examine each projected class and decide whether
the class must be included in the current global hypothe-
sis as a component hypothesis. In the process of forming
beat patterns, causal links between adjacent beats allow
Fig. 8. Various specializations of the class REPETITIVE- RHYTHM-PATTERN.
the system to verify the causal relationship that governs
the pace-making mechanism on a beat-to-beat basis.
While recursively hypothesizing consecutive beat events,
the system can rate the degree of consistency by testing
them against the corresponding wave sequence. Salient
features of the control strategy can be summarized as
follows:
(i) Provision for means of hypothesis projection accross
distinct KBs.
(ii) Exploitation of causal knowledge about cardiologi-
cal events.
(iii) Recognition of repetitive event sequences and detec-
tion of beat-to-beat relationship.
4.4. Control strategy for the fuzzy rule based system
Fig. 9 shows the block diagram of the fuzzy-rule-based
system [71,75}78] designed for interpretation of ECG
patterns. The strategy followed for forming the necessary
sequence of inferences by the system is in principle
same as that illustrated in Section 3.4.1 for the rule-based
system. But the rule of inference that guides a single rule
application under fuzzy logic is not same as MP (Modus
Ponens) of two-valued logic. Since fuzzy logic allows
imprecise mode of reasoning, a multitude of separate
rules, accounting for each possible variation of pattern
primitives of the ECG cycle, need not be introduced as
would have otherwise been necessary for accommodating
these variations within the system based on two-valued
logic. Consider an example. In the rule-based arrhythmia
recognition system that was designed to work under
two-valued logic, an average heart rate of 100 beats per
minute was used as a line of demarcation between ECG
patterns of normal pacing beats and Sinus tachycardia.
There, a heart rate of 105 beats per minute is interpreted
as a case of Sinus tachycardia, whereas, in reality, it is
closer to a case of Sinus tachycardia rather than a clear
one. In order to take care of such variations in the ECG
patterns, the present system, equipped with Generalized
Modus Ponens (GMP) [74], can perform quali"ed diag-
nosis. Here an average heart rate of 105 beats per minute
is expressed in the form of a fuzzi"ed fact as &average-
heart-rate(ECG-cycle) is more-or-less-HIGH' and this
cannot exactly satisfy the precondition in the above con-
ditional proposition. In such cases, the inference, under
GMP, is drawn by correlating the existing fact with the
rule's precondition as follows:
Fact: (average-heart-rate (ECG-cycle) is more-or-
less-HIGH)
Rule: (diagnosis (ECG-cycle) is
SINUS-TACHYCARDIA)
If (average-heart-rate(ECG-cycle) is HIGH)
Inference: (diagnosis(ECGcycle) is more-or-less-SINUS-
TACHYCARDIA)
The above example illustrates that a composite con-
straint, from the given propositions, is induced into the
inference, as an inferred fuzzy relation more-or-less-
SINUS-TACHYCARDIA, through a process of con-
straint propagation. The inferred fuzzy relation is ob-
tained by Zadeh's compositional inference rule [74] as
follows:
Fact: (X is AH)
Rule: (X is A)N(> is B)
Inference: (> is BH)
Fig. 9. The system for fuzzy logic-based ECG interpretation.
where,
BH"AH (ANB),
with being the symbol for Zadeh's compositional infer-
ence rule,
H
B
(v)"max
S
+min(
A*
(u),
B
'
A
(u, v)),, u3;, v3<,
where ; is the universe of discourse for A and AH and
< is the universe of discourse for B and BH.
The above computation can be viewed as a vec-
tor}matrix product with multiply and add operations
replaced by min and max [74,83], respectively.
Rules with more than one conjunctively related fuzzy
preconditions of the form
((X
is A
) (X
is A
)N(> is B))
are to be expressed as
(((X
is A
)N(> is B)) R((X
is A
)N> is B)))
to allow to draw inferences as follows:
Fact 1: (X
is AH
)
Fact 2: (X
is AH
)
Rule: (((X
is A
) N(> is B)) R((X
is A
)
N(> is B)))
Inference: (> is (BH
; BH
))
In order to compute the union of two fuzzy relations, the
following expression [74] can be used:
B
H
u B
H
(v)"max(
H
(v),
H
(v))
where v3< and < is the universe of discourse for B,
B
H
and B
H
.
The rules, which have nonfuzzy relations in their con-
clusions, give nonfuzzy inferences when applied over the
facts.
4.4.1. Rule selection mechanism
Matching the fuzzy preconditions of rules with existing
facts necessitates matching of the corresponding fuzzy
relations. For this, a normalized distance measure d
L
be-
tween fuzzy relations A and AH, both of which are de"ned
in the same universe of discourse ;, is selected as a
measure of dissimilarity. It is computed as follows:
d
L
(A,AH)"
1
n
L
G
"
A
(u
G
)!
H
A
(u
G
)"
where ; is the universe of discourse for A and AH, u
G
3;
and n is the cardinality of ;.
The said measure is experimentally found best [71,75]
for the fuzzy relations, involved with the present applica-
tion. In order to match conjunctively related precondi-
tions of a rule against the existing facts, the maximum of
all dissimilarities arising out of the said preconditions is
to be considered. The block for &Rule Selection Mecha-
nism' in Fig. 9 works for computing the dissimilarity
measures for all applicable rules. Selection of a rule,
which has the minimum dissimilarity measure with re-
spect to the facts about the current ECG cycle, is also the
task of this block.
4.4.2. Linguistic approximation function
The block &Linguistic Approximation Function',
shown in Fig. 9, works to "nd an equivalent linguistic
expression for the inferred fuzzy relation, delivered from
the control system. It checks for dilation or concentra-
tion in the inferred fuzzy relation by comparing the sum
of its membership values with that of its normal variant.
A dilated relation is comprehended by putting the modi-
"er &more-or-less', before the relation name, whereas a
concentrated one is comprehended by putting the modi-
"er &very' before the same.
4.5. Rule-based ECG interpretation with a distributed
control
A distributed reasoning approach is followed in
Refs. [69,71] for rule-based ECG interpretation. The
task of the control system, described in Section 3.2, is
subdivided here into two subtasks. The subtasks are
performed by two cooperating submodules which are
capable of communicating with each other through spe-
ci"ed communication paths. Such parallelism in the func-
tions of the control system is utilized to enhance the
speed of ECG interpretation process. The approach, fol-
lowed here for modularization of the control system, also
makes the conditions for development and maintenance
of the system more favourable.
Distributed reasoning systems are very suitable for
exploiting the inherent parallelism that often exists in
a rule-based system. Such parallelism may broadly be
classi"ed as
(1) Match level parallelism.
(2) Task level parallelism.
For the ECG interpretation problem, studied here, the
match level parallelism is more relevant. The two main
aspects of match level parallelism are
(i) Production level parallelism.
(ii) Condition level parallelism.
Production level parallelism refers to the situation
where a fact, when available, may be made to match with
the preconditions of all the rules of the rule base simulta-
neously instead of sequentially. Condition level parallel-
ismrefers to the situation when evaluating the antecedent
of a rule requires the testing of more than one precondi-
tions and all these preconditions may be tested concur-
rently instead of one after another sequentially.
The objective of the distributed reasoning system that
performs ECG interpretation is to speed up the inference
system by reducing the length of match}resolve}act cycle
for rule "ring. It tries to exploit the production level
parallelism present in the rule base. In the proposed
system, the tasks of matching and rule selection are
carried out concurrently.
Another important objective of this system is to in-
crementally process the ECG waveform. With incremen-
tal processing, it is possible to process each component
fact about an ECG cycle as soon as it is available instead
of waiting for the remaining facts about the cycle to be
computed. Thus, the aim of the incorporation of the
capability of incremental processing is to make the pro-
posed system more suitable for on-line processing of
ECG signals as required in the ICCU.
Fig. 10 shows the block diagram of the system. At the
core of the system there is a rule-based expert which
works over the facts, prepared in succession by the pre-
processing and wavefeature extraction modules. The
rule-based expert has all its usual components, as men-
tioned before. Every entry of the fact base corresponds to
a predicate and links all rules which use the predicate as
precondition. The di!erent arrhythmia classes alongwith
a class of normal ECGs constitute the goal expression as
disjunctions of literals and correspond to di!erent entries
of the goal base. There are certain subgoals, like &(QRS
complex is abnormal)', as shown in Fig. 7, which require
assertion after they are proved. This is to facilitate further
inferences. For example, once a ventricular premature
beat (VPB) is detected with an abnormal QRS complex
occuring in a premature R-R interval, the next question
arises whether it is a case of Ventricular tachycardia with
more than two VPBs occurring successively at a heart
rate of 150 beats/min or more. So every entry of the goal
base, which corresponds to a particular goal or subgoal,
stores certain actions to be followed after the goal or
subgoal is proved. Entries of the rule base correspond to
di!erent rules which are same as those described in
Section 3.2. The consequent part of every rule bears a
reference to a goal or subgoal. This is denoted through
a link fromthe corresponding entry of the rule base to the
appropriate entry of the goal base. The inferences drawn
by the control module through a sequence of rule ap-
plications are stored in the archival storage of informa-
tion outside the system.
The control system, which always maintains a list of
partially applicable rules on the basis of the latest avail-
able facts, attempts to "re an appropriate one from the
list after the arrival of every piece of fact. All functions of
the control system can be better understood if it is con-
sidered to be consisting of two concurrent processes
capable of communicating with each other. The pro-
cess(C1) always checks if a fact arrives and, on receiving
Fig. 10. Rule based ECG interpretation system with distributed control.
a fact, it sends a copy of the list of applicable rules
corresponding to the fact from the fact base to the pro-
cess(C2). The process(C2) always maintains a list of
partially applicable rules on the basis of the most recently
available facts by taking union of the existing list and the
list received from the process(C1). If all preconditions for
any of the rules from the union are found satis"ed, then
the process(C2) immediately "res the rule after making
the current list null. Firing of a rule is followed by
creation of diagnositic instances by process(C2) if an
abnormality is detected in the input signal. Process(C2),
guided by the actions enlisted in the Goal table, also
sends the proven subgoal to process(C1) if it requires
assertion, after being proved.
It may also be noted that the implementation here is fast
enough so that all facts of an ECG cycle are completely
processed before the arrival of facts about the next cycle.
5. Connectionist approaches
Connectionist approaches [79], also known as arti"-
cial neural networks (ANNs) based approaches, seek to
develop simpli"ed cell (neuron) level models of the biolo-
gical neural networks for drawing inferences. Informa-
tion in ANNs are encoded in the connection weights and
learning is achieved by suitably adjusting the strengths of
connections between neurons, i.e., by weight updation.
The features of an ANN, which make it attractive for
ECG interpretation, are its adaptivity to frequently
changing scenario, robustness to imprecision and uncer-
tainty, massive parallelism and high degree of intercon-
nections, and "nally its fault tolerant capability.
A fuzzy rule-based system has already been discussed
in respect to its e!ectiveness to deal with imprecision and
uncertainty, prevailing in the ECG patterns. However, it
requires quite an intensive amount of computation which
can otherwise be well managed by an ANN. The problem
of detecting biologically signi"cant points in noisy and
time variant ECG patterns has also been discussed pre-
viously. An ANN, due to its learning ability, may be
a suitable choice for this. Unlike the rule based system,
which relies on the expert's input, the ANN models,
used for ECG interpretation, o!er the advantage of
knowledge base, derived directly from the set of training
examples. Such ANN-based systems with generalization
Fig. 11. Comparison of diagnoses performed through two valued logic and fuzzy logic on data set (C4).
capability are adaptive to the variations of the input
ECGs and once trained are capable of providing diag-
nosis speedily.
Multi layer perceptron (MLP) and adaptive resonance
theory (ART) networks are the important models of
ANNs, which in the recent time have been successfully
applied for solving various subproblems of ECG inter-
pretation. Applications of MLPs in removal of noise
from the ECG data [81], and for recognition of fatal
arrhythmias like VF and VT [62,81] have shown en-
couraging results. Some ART networks have also been
applied for extracting wave features from the ECG pat-
terns. A Fuzzy ARTMAPnetwork [81] has been success-
fully used for R wave detection. Two ART networks
[80,81] have been applied for establishing the search
regions for Q and S points. The performance of the
system for detection of Q and S points with ART2 net-
works has been experimentally found to be more robust
than the conventional slope detection method [84]. The
average recognition errors for Q and S points are found
to be 0.59 and 0.60 ms, respectively, under the said sys-
tem. Compared to the 4 ms sampling interval of AHA
database, the rates of occurrences of an error more than
4 ms are only 1 and 2% for Q and S points, respectively.
6. Discussion
It is clear from the previous sections that the primary
objective of all the knowledge based ECG interpretation
approaches is closer modeling of cardiological domain
knowledge for better diagnosis of ECG patterns. In
ful"lling this objective, each approach is devised with
one particular knowledge representation technique.
AND/OR graph representation, "rst order predicate
logic (FOPL), procedural semantic network and fuzzy
logic are the knowledge representation techniques fol-
lowed there. The ECG interpretation approaches which
are based on AND/OR graph, FOPL and fuzzy logic use
the morphological domain knowledge of the ECG pat-
tern only, whereas the CAA system which is based on
PSN uses the knowledge of cardiac conduction system in
addition to that of the ECG pattern.
The CAA system can be taken as a model to show how
the physiological knowledge of the individual electrical
discharges can be correlated with the morphological
knowledge of the ECG pattern to achieve a very high
degree of reliability (over 80%) in diagnosing abnormal
ECGs, compared to certain traditional ECG analysis
programs [66}68]. But due to non availability of in-
formation about its response time, the question about its
suitability of use in the ICCU remains unanswered here.
The rule-based system that was experimentally found
to have taken on the average 0.5158 ms, on an 80286
based PC/AT with 12 MHz clock rate, is suitable for
ICCU application. However, the rule based system,
working under two valued logic, lacks the ability of
dealing with incomplete and imprecise knowledge,
which is very common in medical diagnosis of ECGs.
The fuzzy logic based system is experimentally found
to have improved performances in this regard. Fig. 1
shows two outputs obtained from the same lead II
ECG data by rule based system and the fuzzy logic
based system respectively. Diagnoses, obtained through
two valued logic and fuzzy logic, are shown on the
same diagram of Fig. 11. The diagnoses with two valued
logic appear at the top and that with fuzzy logic appears
at the bottom of the diagram. The diagnoses for
cycle(C1) of data set(C4) are obtained as &(QRS complex
is more-or-less-NORMAL) and (diagnosis is more-or-
less-SINUS-BRADYCARDIA)' from the fuzzi"ed facts
like &(QRS duration is NORMAL), (QRS amplitude is
Fig. 12. (a) The result of noise removal from ECG data with the MLP network. (b}c) Diagnoses performed through the MLP network
for VF and VT detection. (d) The results of "ducial point detection in ECG data with the system of two fuzzy ARTMAP networks.
more-or-less-NORMAL) and (average heart rate is
more-or-less-LOW)'.
When the result of this diagnosis is compared with that
obtained through two valued logic, it is observed that
fuzzy logic-based system takes care of "ner variations in
the input ECG patterns and quali"es the diagnosis with
the modi"er &more-or-less', which was in previous case
a plain one. This is achieved through fuzzi"cation of facts
Fig. 12. (Continued.)
and approximation of diagnoses and, of course, with-
out the need of adding any new rule to the existing
rule base, used previously for two valued logic [70,71].
The average heart rate in data set(C4) is 57 beats/min.
Assuming 60 beats/min to be the normal heart rate,
the "ner variations of the heart rate, slightly di!erent
from the normal, is well detected by the fuzzy method
without calling for addition of any new rule. This is
made possible by enabling the rule based system to deal
with the inexact and incomplete knowledge. The average
execution time required for interpretation of an ECG
cycle on an 80286 based PC/AT with 12 MHz clock rate
was observed as 153 ms Even this time of 153 ms is much
less than the average time period (1000 ms) of a normal
ECG cycle. Thus, the requirement for diagnosing ECG
signals from multiple patients is amply satis"ed with this
method and it also provides a more appropriate ap-
proach to better diagnosis of multiple patients in real
time.
As the fuzzy logic based approach shows one direction
of work, branching from the rule based approach in view
of improving the quality of ECG diagnosis, the distrib-
uted control algorithm shows another direction of work,
branching from the same in view of enhancing the speed
of ECG interpretation.
The distributed control algorithm for the rule-based
arrhythmia recognition system was tested with real ECG
data, under a simulated environment. The computer sys-
tem, used for the work, was 80286 based PC/AT with 12
MHz clock rate. With the said experimental setup, the
average processing time for arrhythmia recognition was
observed as 0.3968 ms per ECG cycle. The system speed-
up as compared with the serial version of the control
algorithm is calculated as 1.3("0.5158 ms/0.3968 ms)
from the experimental results. The gain may be higher if
the size of the rule base used for the prototype system is
extended.
Some of the results, obtained through the above men-
tioned connectionist approaches on ECG data, are
shown in Figs. 12(a)}(d). Fig. 12(a) shows the e!ect of
using the MLP network on ECG data for noise removal.
Figs. 12(b) and (c) show accurate detection of two fatal
arrhythmias, requiring special attention, with the use of
another MLP network, mentioned previously in Sec-
tion 5. Fig. 12(d) shows accurate detection of "ducial
points in ECG data by application of the fuzzy AR-
TMAP networks, also referred to in Section 5. All these
results are encouraging ones.
7. Future directions of the work
One major di$culty in replicating the physician's
knowledge through predicate calculus expressions is that
sometime physicians prefer to express their experiences
with dispositions like Ùsually such thing happensa or
`Quiet often such thing happensa. Modeling of the dispo-
sitional knowledge [74] is necessary for betterment of
the ECG diagnosis. Application of fuzzy logic can be an
appropriate "eld of study in resolving this problem. For
knowledge based interpretation of other bio-electic sig-
nals like Carotid-Pulse wave, Electro-encephalogram
(EEG), Blood pressure wave [8], etc., which follow
a regular pattern under the normal condition of the
human body, the present technique can provide some
useful hints to the researchers.
The ECG interpretation system, for which the average
time needed for diagnosing each ECG cycle is much less
than the time period of an ECG cycle, can be further
studied for the development of a real-time multipatient
cost e!ective ECG interpretation system.
In order to integrate the power of fuzzy logic with that
of the neural networks, investigations are going on for
exploring the scope of application of certain neuro-fuzzy
models [85] for ECG interpretation under the CMATER
Project at Jadavpur University.
Acknowledgements
The work is partly supported by the `Development of
Fuzzy Logic Technology for interpretation of Bioelectric
Signalsa project of the Centre for Microprocessor Ap-
plication for Training Education and Research, Depart-
ment of Computer Science and Engineering, Jadavpur
Unviersity. The project was funded by the AICTE, Gov-
ernment of India.
References
[1] M.J. Goldman, Principles of Clinical Electrocardiogra-
phy, 11th Edition, Lange Medical Publications, Drawer
L, Los Altos, California 94022.
[2] D. Rowlands, Understanding the Electrocardiogram:
A New Approach, Churchill Livingstone, Medical
Division of Longman Group Ltd., ISBN 0443025061,
1980.
[3] M.B. Conover, Pocket Guide to Electrocardiography,
Galgotia Pub. Pvt. Ltd., New Delhi, 1989.
[4] H.W. Day, An intensive coronary care area, Dis. Chest,
44 (1963) 423}427.
[5] B. Lown, M.D. Klein, P.I. Hershberg, Coronary and
precoronary care, Amer. J. Med. 46 (1969) 705}724.
[6] L.J. Thomas Jr., K.W. Clark, C.N. Mead, K.L. Ripley,
B.F. Spenner, G.C. Oliver Jr., Automated Cardiac
disrhythmia analysis, Proc. IEEE 67 (9) (1979)
1322}1399.
[7] N.J. Holter, New method for heart studies, Science 134
(1961) 1214}1220.
[8] J.R. Cox Jr., F.M. Nolle, R.M. Arthur, Digital analysis
of the electroencephalogram, the blood pressure wave,
and the electrocardiogram, Proc IEEE 60 (1962)
1137}1164.
[9] S.L. Horowitz, A syntactic algorithm for peak detection
in waveforms with applications to cardiography, CACM
18 (5) (1975) 281}285.
[10] E. Skordalakis, Syntactic ECG processing: a review,
Pattern Recognition 19 (4) (1986) 305}313.
[11] K. Udupa, I.S.N. Murthy, Syntactic approach to ECG
rhythm analysis, IEEE Trans. Biomed. Eng. BME-27 (7)
(1980).
[12] M.L. Ahlstrom, W.J. Tompkins, Automated high speed
analysis of Holter tapes with microcomputers, IEEE
Trans. Biomed. Eng. BME-30 (10) (1983) 651}657.
[13] P.W. Macfarlane, ECG waveform identi"cation by
digital computer, Cardiovasc. Res. 5 (1971) 141}146.
[14] M. Kunt, H. Rey, A. Lightenberg, Preprocessing of elec-
trocardiograms by digital techniques, Signal Processing
4 (2&3) (1982) 215}222.
[15] C.H.H. Chu, E.J. Delp, Impulse noise suppression and
normalization of electrocardiogram signals, IEEE Trans.
Biomed. Eng. 36 (2) (1989).
[16] T. Pavilidis, S.L. Horowitz, Segmentation of plane curves,
IEEE Trans. Comput. C-23 (8) (1974) 860}870.
[17] G. Papakonstantinou, F. Gritzali, Syntactic "ltering of
ECG waveforms, Comput. Biomed. Res. 14 (1981)
158}167.
[18] W.C. Mueller, Arrhythmia detection program for an am-
bulatory ECG monitor, Biomed. Sci. Instrum. 14 (1978)
81}85.
[19] J.P. Abenstein, W.J. Tompkins, A new data reduction
algorithm for real time ECG analysis, IEEE Trans.
Biomed. Eng. BME-29 (1) (1982) 43}48.
[20] J.R. Cox et al., Compact digital coding of electrocardio-
graphic data, in Proceedings of the sixth Hawai Interna-
tional Conference of System Science (Honolulu, Hawaii),
1973, pp. 333}336.
[21] M.E. Womble et al., Data compression for storing and
transmission of ECGs and VCGs, Proc. IEEE. 65 (5)
(1977) 702}706.
[22] P.O. Borjesson, O. Pahlm, Predictive coding for ECG
data compression, Tech. Rep. TR-87, Dept. of Tele-
communication Theory, University of Lund, Sweden,
1977.
[23] U.E. Ruttimann, H.V. Pipberger, Compression of the
ECG by prediction of interpolation and entropy encod-
ing, IEEE Trans. Biomed. Eng. BME-26 (11) (1979)
613}622.
[24] N. Ahmed, P.J. Milne, S.G. Harris, Electrocardiographic
data compression via orthogonal transforms, IEEE
Trans. Bomed. Eng. BME-22 (6) (1975) 484}487.
[25] A. Sandaman, B. Sapir, Third order polynomial-its use in
data compression, Signal Processing 15 (4) (1988)
405}418.
[26] C.N. Mead, T. Ferriero, K.W. Clark, L.J. Thomas, Jr.,
J.R. Cox, Jr., G.C. Oliver, An improved Argus/H system
for high-speed ECG analysis, Comp. Cardiol. (IEEE Cat.
No. 75CH1018-C), 1975, pp. 7}13.
[27] R. Dillman, N. Judell, S. Kuo, Replacement of AZTECby
correlation for more accurate VPB detection, Comp.
Cardiol, (IEEE Cat. No. 78CH1391-2C), 1978, pp. 29}32.
[28] W. Rey, J.D. Laird, P.G. Hugenholtz, P-wave detection
by digital computer, Comput. Biomed. Res. 4 (1971)
509}522.
[29] G. Belforte, R. De Mori, F. Ferraris, Acontribution to the
automatic processing of electrocardiograms using syn-
tactic methods, IEEE Trans. Biomed. Eng. BME-26
(1979) 125}136.
[30] F. Gritzali, Towards a generalized scheme for QRS detec-
tion in ECG waveforms, Signal Processing 15 (2) (1988)
183}192.
[31] W.P. Holsinger, K.M. Kempner, M.H. Miller, A QRS
preprocessor based on digital di!erentiation, IEEE
Trans. Biomed. Eng. BME-18 (1971) 212}217.
[32] A. Ligtenberg, M. Kunt, A robust digital QRS detection
algorithm for arrhythmia monitoring, Comput. Biomed.
Res. 16 (1983) 273}286.
[33] G.M. Friesen et al., A comparison of the noise sensitivity
of nine QRS detection algorithms, IEEE Trans. Biomed.
Eng. 37 (1) (1990) 85}98.
[34] W.A.H. Engelse, C. Zeelenberg, A single scan algorithm
for QRS-detection and feature extraction, IEEE Comput.
Card., IEEE Computer Society, Long Beach, 1979, pp.
37}42.
[35] P.M. Mahoudeaux et al., Simple microprocessor based
system for on-line ECG analysis, Med. Bio. Eng. Com-
put. 19 (1981) 497}500.
[36] J. Fraden, M.R. Neuman, QRS wave detection, Med.
Biol. Eng. Comput. 18 (1980) 125}132.
[37] C.L. Feldman, M. Hubelbank, Cardiovascular monitor-
ing in the coronary care unit, Med. Instrum. 11 (5)
(1977).
[38] J.M. Arnold, P.M. Shah, W.B. Clarke, Arti"cial rejection
in a computer system for the monitoring of arrhythmias,
Comput. Cardiol. (IEEE Cat. no. 75CH1018-1C), 1975,
pp. 163}167.
[39] R. Dillman, N. Judell, S. Kuo, Replacement of AZTEC
by correlation for more accurate VPB detection,
Comput. Cardiol. (IEEE Cat. No 78CH1391-2C), 1978,
pp. 29}32.
[40] Quin-Lan Cheng, Ho Soo Lee, N.V. Thakor, ECG wave-
form analysis by signi"cant point extraction - II, Com-
put. Biomed. Res. 20 (1987) 428}442.
[41] K.P. Lin, W.H. Chang, QRS feature extraction using
linear prediction, IEEE Trans. Biomed. Eng. 36 (10)
(1989) 1050}1055.
[42] P. Trahanias, E. Skordalakis, G. Papakonstantinou,
A synatactic method for the classi"cation of the QRS
patterns, Pattern Recognition Lett. 9 (1989) 13}18.
[43] E. Skordalakis, P. Trahanias, Primitive pattern selection
and extraction in ECG waveforms, in Proceedings of
eighth International Conference on Pattern Recognition,
1986, pp. 380}382.
[44] S.H. Rappaport, L. Gillick, G.B. Moody, R.G. Mark,
QRS morphology classi"cation: quantitative evaluation
of di!erent strategies, Comput. Cardiol. 1982, pp. 33}38.
[45] E. Kimura, Y. Mibikura, S. Miura, Statistical diagnosis of
electrocardiogram by theorem of Bayes, Jpn. Heart J.
4 (1963) 469}488.
[46] G. Papakonstantinou, E. Skordalakis, F. Gritzali, A at-
tribute grammar for QRS detection, Pattern Recognition
19 (4) (1986) 297}303.
[47] G. Papakonstantinou, An interpreter of attribute gram-
mars and its application to waveform analysis, IEEE
Trans. Software Eng. SE-7 (3) (1981) 279}283.
[48] R.E. Bonner et al., A new computer program for analysis
of scalar electrocardiograms, Comput. Biomed. Res.
5 (1972) 629}653.
[49] D.A. Coast, R.M. Stern, G.G. Cano, S.A. Briller, An
approach to cardiac arrhythmia analysis using hidden
Markov models, IEEE Trans. Biomed. Eng. 37 (9) (1990)
826}836.
[50] W. Gersch, P. Lilly, E. Dong Jr., PVC detection by the
heart-beat interval data-Markov chain approach, Com-
put. Biomed. Res. 8 (1975) 370}378.
[51] R.V.H. Vinke et al., Classi"cation of cardiac rhythms
using theory of Markov chains, in: Comput. Cardiol.
Vol. 6, IEEE, New York, 1979, pp. 255}258.
[52] P. Schluter, D. Clapham et al., The design and evalua-
tion of a computer based system for holter tape analy-
sis, in: Comput. Cardiol., IEEE, New York, 1984,
pp. 193}196.
[53] C.L. Feldman, Computer Based Holter Scanners } Cur-
rent Status, Cardiodata, Northboro, MA, 1984.
[54] M. Kundu et al., Microprocessor based on-line feature
extraction technique for ECG waveform, in: Proceedings
of Third Syposium International de lngineria Biomedica,
Madrid, Spain, 7}9 Oct. 1987, pp. 385}389.
[55] M. Nasipuri, D.K. Basu, R. Dattagupta, M. Kundu,
S. Banerjee, A new microprocessor based on-line ar-
rhythmia diagnostic system, in: Proceedings of IEEE
Region Ten Conference (TENCON '87), Seoul, Korea,
26}28 Aug. 1987, pp. 1187}1191.
[56] M. Nasipuri, D.K. Basu, M. Kundu, R. Dattagupta,
A new microprocessor based system for on-line data
reduction of ECG signal and arrhythmia detection, in:
Proceedings of Biomedizinische Technik 88, Universitat
Stuttgart, 7}10 Sep. 1980, pp. 75}76.
[57] M. Nasipuri, D.K. Basu, R. Dattagupta, M. Kundu,
S. Banerjee, Microprocessor based real-time monitoring
of multiple ECG signals, in Proceedings of Eleventh
Annual Symposium on Computer Applications in Medi-
cal Care (SCAMC), Washington D.C., U.S.A., 1}4 Nov.
1987, pp. 822}827.
[58] M. Nasipuri, M. Kundu, D.K. Basu, Microproces-
sor based simultaneous processing of multiple holter
tapes, in: Proceedings IEEE Region Ten Conference
(TENCON '89), Bombay, 22}24 Nov. 1989, pp.
500}502.
[59] M. Kundu et al., A parallel architecture for real time
recognition of ECG waveforms, J. Inst. Eng. (India) 73
(Part ET4) (1993) 158}161.
[60] N.V. Thakor, Y.S. Zhu, K.V. Pan, Ventricular tachycar-
dia and "brillation detection by a sequential hypothesis
testing algorithm, IEEE Trans. Biomed. Eng. 37 (9)
(1990) 837}843.
[61] P. Trahanias, E. Skordalakis, Syntatic pattern recogni-
tion of the ECG, IEEE Trans. Pattern Anal. Mach. Intell.
PAMI-12 (7) (1990) 648}657.
[62] Z. Yi-Sherg, N.V. Thakor, Ventricular tachycardia and
"brillation detection by a sequential hypothesis testing
algorithm, IEEE Trans. Biomed. Eng. 37 (9) (1990)
837}843.
[63] P.M. Shah et al., Automatic real-time arrhythmia
monitoring in the intensive coronary care unit, Am. J.
Cardiol. 39 (4) (1977).
[64] G. Stockman, L. Kanal, M.C. Kyle, Structural pattern
recognition of carotid pulse waves using a general wave-
form parsing system, CACM 19 (12) (1976) 688}695.
[65] F.L. Xiong, B.A. Lambird, L.N. Kanal, An experiment in
recognition of electrocardiogram using a structural anal-
ysis algorithm, in Proceedings of IEEE International
Conference on Systems, Man and Cybernetics, Bombay
and New Delhi, Dec. 1983 } Jan. 1984, pp. 382}387.
[66] T. Shibahara et al., CAA: a knowledge based system using
causal knowledge to diagnose cardiac rhythm disorders,
Tech. Reps. on Research at the Laboratory for Computa-
tional Medicine at the University of Toronto, LCM-
TR84-1, May 1984.
[67] J.K. Tsotsos, T. Shibahara, Knowledge organization and
its role in temporal and causal signal understanding:
the ALVEN and CAA projects, in: N. Ccercone,
G. McCalla (Eds.), The Knowledge Frontier, Springer,
Berlin, 1987.
[68] J. Mylopoulos, T. Shibahara, J.K. Tsotsos, Building
knowledge-based systems: the PSN experience, IEEE
Comput. 16 (10) (1983) 83}88.
[69] M. Kundu et al., A reasoning system for on-line inter-
pretation of ECG signal, accepted in IEEE Region Ten
Conference (TENCON'93), Beijing, 19}21 October 1993.
[70] M. Kundu, M. Nasipuri, D.K. Basu, A rule-based expert
system for real-time interpretation of ECG patterns, in:
Proceedings of International Seminar held on occasion
of Ninth Indian Engineering Congress at Calcutta, Vol.
2, 15}20 Dec. 1994, pp. 827}838.
[71] M. Kundu, Studies on some AI techniques for interpreta-
tion of ECG waveforms, Doctoral Dissertation, Com-
puter Sc. & Engg. Dept., Jadavpur University, India,
1994.
[72] C.A. Steinberg, S. Abraham, C.A. Caceres, Pattern recog-
nition in the clinical electrocardiogram, IRE Trans. Bio-
med. Electron. BME-9 (1962) 23}30.
[73] G.C. Stockman, L.N. Kanal, Problem reduction repres-
entation for the lingusitic analysis of waveforms, IEEE
Trans. Pattern Anal. Mach. Intell. PAMI-5 (3) (1983)
287}298.
[74] L.A. Zadeh, Fuzzy logic, IEEE Comput. (1988) 83}89.
[75] M. Kundu, M. Nasipuri, D.K. Basu, A knowledge based
approach to ECG interpretation using fuzzy logic, IEEE
Trans. Systems Man Cybernet}Part B 28 (2) (1998)
237}243.
[76] M. Kundu et al., A fuzzy expert system for interpretation
of arrhythmia in ECG signal, in: Proceedings of Ko-
rea/Japan Joint Conference on Expert Systems with the
Third World Congress on Expert Systems and others,
Seoul, Korea, 2}5 Feb. 1993, pp. 567}579.
[77] M. Kundu et al., An approach for reasoning with uncer-
tainties in interpretation of bio-electrical signals, in:
Proceedings of Ninth International Congress of Cyber-
netics and Systems, World Organization of Systems
and Cybernetics, New Delhi, India, 18}23 Jan. 1993,
pp. 372}376.
[78] M. Kundu et al., An expert system for qualitative decision
making in interpretation of ECG signals, XVIII Annual
Convention and Exhibition (ACE '92) organized by
IEEE Calcutta Section and BITM Calcutta, 21}23 Nov.
1992, pp. 204}207.
[79] A.K. Jain, J. Mao, K.M. Mohiuddin, Arti"cial neural
networks: a tutorial, IEEE Comput. (1996) 31}44.
[80] Suzuki, Self-organizing QRS wave recognition in ECG
using neural networks, IEEE Trans. Neural Networks
6 (6) (1995) 1469}1477.
[81] K. Paul, A connectionist approach to ECG interpreta-
tion, M.C.S.E. Thesis, Comp. Sc. & Eng. Dept., Jadavpur
University, Calcutta, India, 1997.
[82] N.J. Nilson, Principles of Arti"cial Intelligence, Springer,
Berlin, 1982, pp. 193}273.
[83] Meng-Hiot Lim, Yoshiyasu Takefuji, Implementing fuzzy
rule-based systems on silicon chips, IEEE Expert 5 (1)
(1990) 31}45.
[84] M. Okajima, Computer Diagnosis of Electrocardiogram,
Nakayama Shoten, Tokyo, 1989 (in Japanese).
[85] S.K. Pal, S. Mitra, Multi layer perceptron, fuzzy sets and
classi"cations, IEEE Trans. Neural Networks 3 (5) (1992)
683}697.
[86] H.V. Pipberger et al., Preparation of electrocardiographic
data for analysis by digital electronic computer, Circula-
tion 21 (1960) 413}418.
[87] H.V. Pipberger et al., Automatic screening of normal and
abnormal electrocardiograms by means of a digital elec-
tronic computer, Proc. Soc. Exp. Biol. Med. 106 (1961)
130}132.
[88] L.D. Cady, M.A. Woodbury, L.J. Tick, M.M. Gertler,
A method for electrocardiogram wave pattern estima-
tion, Example left ventricular hypertrophy, Circ. Res.
9 (1961) 1078.
[89] H.V. Pipberger, Use of computers in interpretation of
electrocardiograms, Circ. Res. 11 (1962) 555.
[90] L. Stark, M. Okajima, G.H. Whipple, Computer pattern
recognition techniques: electrocardiographic diagnosis,
CACM (1962) 527}531.
[91] T.Y. Young, W.H. Huggins, Computer analysis of
electrocardiograms using a linear regression tech-
niques, IEEE Trans. Biomed. Eng. BME-11 (1964)
60}67.
[92] M.D. Feezor, A.G. Wallace, R.W. Stacy, A real time
uniform analyser for detection of ventricular premature
beats, J. Appl. Physiol. 29 (4) (1969) 541}545.
[93] C.L. Feldman, M. Hubelbank, P.G. Amazeen, Real-time
cardiac arrhythmia monitoring with the PDP-7, DECUS
Proceedings, 1969, pp. 345}353.
[94] L.J. Haywood, V.K. Murthy, G.A. Harvey, S. Saltzberg,
On-line real-time computer algorithm for monitoring
the ECG waveform, Comput. Biomed. Res. 3 (1970)
15}25.
[95] J.R. Cox, Jr., H.A. Fozzard, F.M. Nolle, G.C. Oliver,
Some data transformations useful in electrocardiogra-
phy, Computers in Biomedical Research, Vol. 3, Aca-
demic Press, New York, 1969, pp. 181}206.
[96] Y. Nomura, Y. Takaki, S. Toyama, Automatic measure-
ment of the electrocardiogram by digital computer, Jpn.
Circ. J. 30 (1966) 21}28.
[97] E. Kimura, Automatic interpretation of electrocardio-
gram by electronic computer, Jpn. J. Med. 8 (1969)
182}184.
[98] F.W. Stallmann, H.V. Pipberger, Automatic recognition
of electrocardiographic waves by digital computer, Circ.
Res. IX (1961) 1138}1143.
[99] L. Stark, J.F. Dickson, G.H. Whipple, H. Horibe, Remote
real-time diagnosis of clinical electrocardiograms by
a digital computer system, Ann. N.Y. Acad. Sci. 126
(1967) 851}872.
[100] J. Wartak, J.A. Milliken, J. Karchmar, Computer pro-
gram for pattern recognition of electrocardiograms,
Comput. Biomed. Res. 4 (1970) 344}374.
[101] D. Wortzman, B. Gilmore, H.D. Schwetman, J.I. Hirsch,
A hybrid computer system for the measurement and
interpretation of electrocardiograms, Ann. N.Y. Acad.
Sci. 128 (1966) 876}899.
[102] J. Wartak, Computer-aided recognition of electrocardio-
grams, Acta Cardiol. 22 (1967) 350}361.
[103] S. Yasui et al., Computer diagnosis of electrocardiograms
by means of a joint probability, Israel J. Med. Sci.
5 (1969) 913}916.
[104] J.A. Milliken et al., Use of computers in the interpretation
of electrocardiograms, Can. Med. Assoc. J. 101 (1969)
39}43.
[105] J.M. Neilson, High speed analysis of ventricular ar-
rhythmias from 24 hour recordings, in: Computers
in Cardiology (IEEE Cat. No. 74CH0879-7C), 1974,
pp. 55}59.
[106] F.M. Nolle, G.C. Oliver, R.E. Kleiger, J.R. Cox, Jr., K.W.
Clark, H.D. Ambos, The Argus/H systemfor rapid analy-
sis of ventricular arrhythmias, in: Computers in Cardiol-
ogy (IEEE Cat. No. 74CH0879-7C), 1974, pp. 37}42.
About the Author*MAHANTAPAS KUNDU received his B.E.E, M.E. Tel. E and Ph.D. (Eng.) degrees from the Jadavpur University
(J.U.), Calcutta, India in 1983, 1985 and 1995, respectively. He worked as a Research Engineer in the Centre for Microprocessor
Application for Training Education & Research, J.U., during 1985}88. He joined the J.U. as a faculty member in 1988. He is currently
working as a Reader in the Computer Sc. and Eng Dept., J.U. He has co-authored a text book on computer fundamentals and a number
of research papers in the areas of pattern recognition, image processing, multimedia databases, arti"cial intelligence and bio-medical
signal processing.
About the Author*MITA NASIPURI received her B.E.Tel.E., M.E.Tel.E. and Ph.D. (Eng.) degrees from Jadavpur University,
Calcutta, India in 1979, 1981 and 1990, respectively. She is currently a Professor in the Computer Science and Engineering
Department of Jadavpur University. Her current research interest includes computer architecture, image processing, multi-
media systems, bio-medical signal processing etc. She has about 30 research publications in International/National Journals
and International/National conferences. She is Senior Member of the IEEE, U.S.A. and Fellow of The Institution of Engineers
(India).
About the Author*DIPAK KUMAR BASU received his B.Tel.E, M.E.Tel.E. and Ph.D. (Eng.) degrees from Jadavpur University,
Calcutta, India, in 1964, 1966 and 1969, respectively. He joined the Jadavpur University, Calcutta, India, in 1968, as a faculty member, in
the Electronics and Tele-communication Engineering Department. He is currently a Professor in the Computer Science and Engineering
Department of the same University. His "eld of interest includes digital electronics, microprocessor applications, bio-medical signal
processing, knowledge based systems, image processing and multimedia systems. He has more than 50 research publications. He is
a Fellowof the Institution of Engineers (India) and West Bengal Academy of Science and Technology and a Senior Member of the IEEE.

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Pattern Recognition 33 (2000) 351}373

Knowledge-based ECG interpretation: a critical review

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