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

perceptron in heart rate variability analysis

Yalcin Isler

Izmir Katip Celebi University, Department of Biomedical Engineering, Cigli, Izmir, Turkey

art ic l e i nf o

a b s t r a c t

Article history:

Received 29 January 2016

Received in revised form

26 June 2016

Accepted 28 June 2016

In this study, the heart rate variability (HRV) analysis is used to distinguish patients with systolic congestive heart failure (CHF) from patients with diastolic CHF. In the analysis performed, the best accuracy

performances of short-term HRV measures are compared. These measures are calculated in four different

ways with optional normalization methods of heart rate and data. The nearest neighbor and the multilayer perceptron (MLP) are used to evaluate the performances in discriminating these two groups. The

results point out that using both data and heart rate normalizations enhances the classier performance.

The maximum accuracy is obtained as 96.43% with MLP classier.

& 2016 Elsevier Ltd. All rights reserved.

Keywords:

Heart rate variability

Heart failure

Normalization

Multi-layer perceptron

Nearest neighbor

1. Introduction

When the pumping capacity of a heart reduces, this disorder is

called heart failure. As the accumulation of blood is so common in

patients with heart failure, it is also named congestive heart failure

(CHF). The failing heart does not manage either to pump or to ll

up, which are called systolic heart failure and diastolic heart failure, respectively [1]. Although the most essential element for the

success of the treatment is the reliable and exact diagnosis of CHF,

systolic dysfunction was determined in only half of all cases and

only 46% of physicians tried routinely distinguishing either systolic

or diastolic dysfunctionality in the patients with CHF [2]. The decreased pump function (i.e. systolic CHF) can be measured by

functional cardiac studies (e.g. ECG, BNP, and echocardiogram) [3

5]. On the other hand, the diastolic dysfunction is identiable by

only echocardiogram [6,7].

Almost 90% of physicians routinely performed ECG tests in

patients due to its simplicity [2]. Nonetheless, physicians accepted

that echocardiography is essential in diagnosis whether patient

with CHF is systolic or diastolic in addition to clinical sign and

symptoms [8]. Average waiting time for echocardiography was

1 month and that was 48 h for ECG [2]. Hence, simple and reliable

diagnostic procedures based on ECG may be helpful for primary

care physicians (PCPs) who are responsible for the early diagnosis

of CHF and implementation of adequate therapy.

Analysis of heart rate variability (HRV), derived from the ECG

E-mail address: islerya@yahoo.com

http://dx.doi.org/10.1016/j.compbiomed.2016.06.029

0010-4825/& 2016 Elsevier Ltd. All rights reserved.

beats [9]. The sinoatrial node (SAN) is the pacemaker of the heart

and is responsible for the HRV. The cells of the SAN slowly but

automatically depolarize; when reaching a threshold, they rapidly

depolarize, followed by a repolarization, and the process repeats

itself constantly. The depolarization quickly propagates to the

surrounding cardiac muscle cells and the contraction of the heart

begins. In healthy subjects, the SAN cells generate depolarization

or action potentials at a frequency that is regulated through direct

innervation of both branches of ANS: sympathetic and parasympathetic (or vagal). The parasympathetic branch releases

acetylcholine (ACh) that slows the rate of SAN depolarization,

while the sympathetic branch releases norepineprine that increases the rate of SAN depolarization. The SAN effectively integrates both inputs from ANS, both temporally and spatially, and

this pacemaker activity is often modeled as an integrate pulse

frequency modulation [40]. This is the source of HRV [41].

In 1996, standards in HRV analysis was published by proposing

a number of time- and frequency-domain parameters calculated

from short-term (5-min) and long-term (24-h) HRV data [9]. In

order to achieve the results quickly, short-term (5-min long) HRV

measures have been preferred in many studies. HRV has been used

in a great number of clinical studies including prediction of sudden cardiac death after acute myocardial infarction [10], early diagnosis of diabetic neuropathy [11], dilated cardiomyopathy [12

14], CHF [1520], fetal distress conditions [21], and obstructive

sleep apnea [22].

In addition, Hallstrom et al. presented that rescaling RR

114

increases their discrimination power [23]. If these measures are

calculated using heart rate normalized data, this analysis is called

as heart rate normalized heart rate variability (HRN) analysis

[20]. In a previous study, the discrimination of CHF patients who

are systolic or diastolic was reached by using kNN classier in only

12 patients as a case study [24].

In this study, it is aimed to determine whether systolic or

diastolic dysfunctionality exists in CHF patients using nearest

neighbor and multi-layer perceptron in both HRV and HRN measures. The following section covers brief information about the

methods used in the study including data, obtaining HRV measures, normalization techniques, classication and performance

assessment algorithms with the owchart of the implementation.

Section 3 gives the results. Finally, the results are discussed.

2. Methods

2.1. Experimental protocol

Patients came to the clinics after their breakfast at the morning,

which took approximately 2 h from their home to clinics because

of the morning trafc in Izmir, Turkey. Patients were requested to

rest at least 10 min just before connecting Holter device. After the

connection, patients waited for 10 min in resting position on a

comfortable chair. During this time, the required paper work was

also completed. Then, they left the clinics and continued their

daily life. They came back to the clinics again approximately 24 h

later. 30 patients from all patients were included into the study

after two experts analyzed the data.

The collected data were digitized at 128 samples per second.

There were 115,200 peaks in ECG by supposing 80 beats per

minute during 24 h for each patient. Ectopic beats are excluded

from HRV analysis in general [9]. Deciding such a big amount of

beats whether normal or ectopic is very time-consuming and irritable process for experts. Moreover, this process is costly for

health industry. That is the reason why the rst 5-min segments of

all recorded ECG data are included in this study. In addition, using

only 5-min (300-s) sections of data helps us achieving the discrimination faster and not disturbing the patients longer in a clinic

environment.

2.2. Data

The Holter ECG data used in this study were obtained from the

Faculty of Medicine in Dokuz Eyll University [24]. Two cardiologists decided whether patients would be included into the study

or not. The data included the study are as follows:

Age of the patient, time-domain, frequency-domain and non-linear methods are used in HRV studies. For further details, the studies given in the references could be examined [19,24,20].

Welch periodogram method, which uses fast Fourier transform

(FFT) method, is commonly used for the evaluation of frequency

domain [25]. Thanks to this method, power spectrum density

(PSD) over the data that is sampled at equal interval through the

time can be computed. In this study, HRV data is re-sampled by

using cubic interpolation method at 4 Hz before using FFT and

detrending of data is eliminated for providing stability analysis

[25]. Besides, evaluation of frequency domain obtained by Lomb

periodogram which is developed as an alternative to the classical

PSD method is also used. Owing to this method, PSD can be

computed from directly the HRV data without needing to resample on time domain [2628]. HRV evaluation of conventional

frequency domain for 5-min period is examined in detail by the

recommended standard [9].

There are three frequency bands commonly used in HRV analysis: VLF (00.033 Hz), LF (0.0330.15 Hz) and HF (0.150.4 Hz) [9].

In the evaluation of frequency domain, powers of these frequency

bands from calculated PSD were examined. Therefore, the following frequency domain measures were computed separately for

both methods of Welch periodogram and Lomb periodogram. The

frequency domain analysis contributed to the understanding of

autonomic background of RR interval uctuations in the HR record

[42,43].

On the other hand, wavelet analysis not only makes possible

the examination of one signal for the both time and scale domains

but also eliminates polynomial non-stability [29]. Wavelets are

reported as very useful for analysis of the RR intervals due to this

capability. Thus, Daubechies-4 main wavelet over HRV data resampled at 4 Hz with the 7-level wavelet transform method was

also used in this analysis to calculate the standard frequency domain features of HRV analysis [19].

Furthermore, non-linear measures derived from Poincare map

were used in this study. Poincare plot is a graph that each RR interval is plotted against the previous interval, which visualizes

detailed beating pattern of the heart. The Poincare plot is a popular technique thanks to its simplicity and its proved clinical

ability. Fitting an ellipse to the Poincare plot's shape and calculating measures from the plot is the most popular method among

nonlinear interpretation methods of HRV [3033].

As a result, 29 features were used. Those are obtained from

patient information, time domain evaluation, frequency spectrum

evaluation and non-linear methods with the numbers of 1, 6, 18,

and 4, respectively.

2.4. Normalization

(1) heart rate normalization and (2) data (or feature)

normalization.

Systolic CHF data: 18 patients (11 men and 7 women) with the

Diastolic CHF data: 12 patients (4 women and 8 unknown) with

Since the gender of 8 patients were not recorded, gender was

not used as a possible feature in the study.

HRN =

HRV data is collected after determining QRS wave structure in

the ECG signals because QRS wave structure is the component that

has the most distinctive amplitude values in the ECG signals. After

the determination of QRS using a Matlab implementation of Pan

Tompkins algorithm [38], the time difference between two consecutive R peaks is commonly called RR-interval (Tn = tn tn 1) [9].

60

HRV

NewHR

HRV

(1)

HRV data in seconds, NewHR is the new value of mean HR to be

xed in bpm, HRV is the mean value of whole HRV data in

seconds, and the constant 60 is used to make unit conversion

from bpm (beats-per-minute) to bps (beats-per-second). NewHR

is selected as 75 bpm since it is recommended and applied

value in [23,20].

Feature normalization: The used features must be equalized on

classication and clustering algorithms differs highly compared

to each other [34]. In this study, MINMAX method is used to

make all features in the scale of 0, 1 using:

fi, N =

fi min(fi )

max(fi ) min(fi )

(2)

min(fi ) and max(fi ) are the minimum and the maximum values

of the i-th feature, respectively.

2.5. Statistical analysis

115

In a cross-validation method, database is divided into two

groups. When the rst group (training database) is used for determination of model parameters of a classier, the other group

(test database) is used for testing the performance of the trained

classier [35]. In the leave-one-out cross-validation method, the

classier is trained with the n 1 samples (where n is the number

of samples in data) by leaving one sample for the test in each time.

Then the performances of the classier are calculated as a summation of these test results. In this study, the performance of

classier is determined by calculation of mean value for error of 30

times because there are 30 samples in the data [36].

method to show signicances of differences between measures of

two distinct groups, was used in this study [36]. The software

package of IBM SPSS Statistics version 22, which is one of the most

favorite programs in the literature related to the statistical analysis, is used to nd p-values that show statistical signicances. If the

p-value is less than or equal to 5%, the corresponding measure has

the statistical evidence on discriminating groups [39].

ACC =

TP + TN

TP + TN + FP + FN

(6)

SEN =

TP

TP + FN

(7)

SPE =

TN

TN + FP

(8)

The main idea of the nearest-neighbor (NN) classier is to

predict the class of a test case based on its nearest neighbor. It

predicts the class of the test sample as that of its nearest neighbor.

Although there are many methods to calculate distances, the Euclidean distance is preferred in this paper [35]:

N

dist (j, k ) =

|fi j

fik |2

(3)

i=1

j

sample and fik is the i-th feature of k-th sample.

2.6.2. Multi-layer perceptron (MLP)

Multi-layer perceptron (MLP) is the most commonly used

structure among the applications based on articial neural networks due to its ability in using both linear and non-linear applications. MLP consists of an input layer, one or more hidden

layers, and an output layer [35]. The number of neurons in the

input layer is the number of features (or inputs) and the number of

neurons in the output layer is the number of outputs. The connection between the input-layer neurons and the hidden-layer

neurons which is similar to the connection between the hiddenlayer neurons and the output-layer neurons is calculated with

weights. The weight values are changed until the minimum error

value is found, which is called training. The general output function and the error function are dened as follows:

yi = f wjixi

i=1

E=

1

2

(4)

( di yi )

i

(5)

function, yi is i-th network output, di is i-th expected output. The

technical implementation details of MLP can be found in the welldened literature [35].

classier. Among them, the following one may be the easiest one

[34]:

as true positive (TP); if it is misclassied as diastolic, it is counted

as false negative (FN). If the instance is diastolic and it is classied

as diastolic, it is counted as true negative (TN); if it is classied as

systolic, it is counted as false positive (FP). In the description of

these measures, the positive means the patient with systolic CHF

and the negative means the patient with diastolic CHF in this

study.

2.9. Implementation

The owchart of the implementation of the study is given in

Fig. 1. In this system, the heart rate and the data normalization

processes are applied optionally so these steps are drawn with

dashed line.

The rst stage of the proposed system is the loading of the

5-min HRV data from the hard disk. The next stage covers the

optional heart rate normalization process. The third stage is the

feature extraction. Time-domain, LS algorithm-based PSD and

Poincare plot measures are calculated directly from the HRV data.

Wavelet-based frequency domain measures require evenly sampled data. On the other hand, FFT-based frequency domain measures require both evenly sampled data and at least weakly stationary data. The cubic interpolation method with a rate of 4 Hz

(as offered in [9]) is used to make data evenly sampled and the

smoothness priors eye model with = 1000 (as offered in [37]) is

used to make data stationary. Both FFT- and LS-based frequency

domain PSD measures are calculated using 256 distinct frequency

points between 0 and 0.5 Hz . The wavelet entropy measures from

the resampled data are calculated using DB4 wavelet packet

transform method, which is probably the most preferred one in

the studies related to the HRV analysis [29]. The packets are calculated at the scale of 7 (i.e. 27 = 128 packets) in order to achieve

the limits of HRV frequency bands using 4-Hz resampled data. For

example, the rst packet is equivalent to the VLF band, the 2nd

10th packets are for the LF band, and the 11th32nd packets

116

Fig. 1. Flowchart of the system with optional heart rate and data normalization processes. The dashed lines show the optional steps.

calculated using the method of ellipse tting. At the end of this

stage, the HRV dataset with 29 features (1 for age, 6 time-domain

measures, 6 FFT-based PSD measures, 6 wavelet entropy measures,

6 LS-based PSD measures, and 4 Poincare plot measures) are

constructed. The last stage indicates the classication steps. This

also covers the optional data normalization step. MLP and NN

classiers are used to nd the best classier for distinguishing the

systolic CHF patients from the diastolic CHF patients. Using the

leave-one-out method, the performances of these classiers are

calculated.

If heart rate normalization process is applied, the system uses

the HRV data normalized to a x HR of 75 bpm [23]. If MINMAX

normalization is in use, the data to be applied to the classier is

limited to a range between 0 and 1. For each subject, all the

standard time-domain, frequency-domain (FFT-based, LS-based,

and wavelet entropies), and Poincare plot measures are calculated

by using Matlab 2015a. All the software implementations are

conducted using a portable workstation based on one Intel i7

processor with 32 GB RAM.

3. Results

All the features extracted from the HRV data and the HRN data

are given in Table 1. Statistical signicances (p-values) of HRN

measures are better than those of HRV measures in time-domain

and nonlinear parameters in general.

Statistical signicances (p-values) of measures are summarized

in Table 2 to show the effect of optional data normalization step.

After applying the HRN-based data normalization method, average

statistical signicance values are drastically reduced.

The application is run for eight different congurations:

HR normalization and no MINMAX normalization,

No HR normalization and MINMAX normalization,

HR normalization and MINMAX normalization.

with NN and MLP classiers. The performances of all the congurations are calculated based on their accuracy measures (see

Tables 3 and 4). The results show that using both MINMAX and

heart rate normalization procedures improve the performance of

the classication processes. The maximum accuracy is found to be

96.43% in the conguration of MINMAX and heart rate normalized

117

Table 1

Standard short-term HRV indices: patient information, time-domain, frequency-domain (estimated from periodogram techniques using both FFT and LS algorithms in

addition to wavelet entropy measures), and Poincare plots.

Feature

HRV

HRN

Systolic CHF

Diastolic CHF

Systolic CHF

Diastolic CHF

0.9727 0.38

1.521 7 1.79

1.698 7 2.16

1.0007 2.00

0.006 7 0.01

1.7317 2.13

0.542

0.313

0.379

0.349

0.349

0.360

0.800 7

0.282 7

0.3347

0.0007

0.0007

0.325 7

0.800 7

0.8917

0.996 7

0.250 7

0.0017

1.0097

1.000

0.214

0.257

0.150

0.150

0.236

FFT_LFHF

9.317 14.79

FFT_VLF

401.617 1135.9

FFT_LF

90.346 7 255.53

FFT_HF

2.026 7 5.73

FFT_NLF

0.7347 0.22

FFT_NHF

0.2667 0.22

115.82 7 224.39

4.337 5.30

19.893 7 36.06

0.1807 0.26

0.598 7 0.41

0.402 7 0.41

0.187

0.468

0.705

0.559

0.424

0.414

9.317 14.79

84.658 7 239.45

19.0457 53.87

0.427 7 1.21

0.734 7 0.22

0.2667 0.22

115.82 7 224.39

1.602 7 1.87

10.363 7 19.72

0.059 7 0.07

0.598 7 0.41

0.402 7 0.41

0.187

0.468

0.705

0.559

0.424

0.414

LS_LFHF

2.7157 2.97

LS_VLF

0.229 7 0.19

LS_LF

0.1907 0.12

LS_HF

0.1297 0.08

LS_NLF

0.599 7 0.22

LS_NHF

0.401 7 0.22

0.454 7 0.14

0.220 7 0.19

0.073 7 0.04

0.1737 0.09

0.308 7 0.06

0.692 7 0.06

0.159

0.872

0.075

0.402

0.028

0.028

2.7157

0.229 7

0.1907

0.129 7

0.599 7

0.4017

0.454 7 0.14

0.220 7 0.19

0.0737 0.04

0.1737 0.09

0.308 7 0.06

0.692 7 0.06

0.159

0.872

0.075

0.402

0.028

0.028

WS_LFHF

1.071 7 0.61

1.8077 1.90

WS_VLF

0.390 7 0.49

1.034 7 0.77

WS_LF

1.031 7 0.87

0.583 7 0.72

WS_HF

0.8477 0.49

0.265 7 0.13

WS_NLF

0.4827 0.14

0.543 7 0.20

WS_NHF

0.5187 0.14

0.457 7 0.20

0.315

0.101

0.366

0.039

0.518

0.507

1.0717 0.61

0.390 7 0.49

1.0317 0.87

0.8477 0.49

0.4827 0.14

0.5187 0.14

1.8077

1.034 7

0.583 7

0.265 7

0.543 7

0.4577

1.90

0.77

0.72

0.13

0.20

0.20

0.315

0.101

0.366

0.039

0.518

0.507

SD1

0.4727

SD2

0.579 7

SD1SD2

1.846 7

RATIO

0.582 7

0.348

0.300

0.405

0.448

0.225 7

0.3067

0.398 7

0.581 7

0.7167

1.006 7

1.503 7

0.740 7

0.85

1.26

2.09

0.08

0.236

0.216

0.226

0.444

Time-domain measures

MEAN

0.874 7

SDNN

0.542 7

RMSSD

0.6827

NN20

0.250 7

PNN20

0.0027

SDSD

0.6787

0.34

1.38

1.73

0.71

0.00

1.85

1.26

1.44

5.16

0.38

1.2247

1.7327

4.859 7

0.7327

1.56

2.34

7.85

0.08

Table 2

Average statistical signicances of both HRV and HRN measures.

HRV

HRN

Time-domain measures

Frequency-domain measures (FFT periodogram)

Frequency-domain measures (LombScargle)

Frequency-domain measures (wavelet entropy)

Nonlinear measures (Poincare plot)

0.3820

0.4595

0.2607

0.3077

0.3753

0.2014

0.4595

0.2607

0.3077

0.2805

Mean values

0.3570

0.301

Feature set

Table 3

Classier results of the nearest neighbor classier, SEN is sensitivity (%), SPE is

specicity (%), and ACC is accuracy (%).

HRV

HRN

Before MINMAX

2.97

0.19

0.12

0.08

0.22

0.22

0.52

0.67

1.06

0.32

0.00

1.02

1.18

0.50

0.00

1.19

Table 4

Classier results of the MLP classier, SEN is sensitivity (%), SPE is specicity (%),

and ACC is accuracy (%).

Method

Feature set

0.00

0.62

0.76

0.00

0.00

0.76

After MINMAX

SEN

SPE

ACC

SEN

SPE

ACC

62.50

68.75

75.00

83.33

67.86

75.00

87.50

87.50

83.33

91.67

85.71

89.29

4. Conclusion

In this study, the effects of normalization methods of shortterm HRV feature sets are investigated for their discrimination in

HRV

HRN

Before MINMAX

After MINMAX

SEN

SPE

ACC

SEN

SPE

ACC

68.75

75.00

83.33

91.67

75.00

82.14

81.25

93.75

91.67

100.00

85.71

96.43

of different combinations of 29 distinct short-term HRV measures

are investigated using HRV data obtained from the Faculty of

Medicine in Dokuz Eyll University. In order to achieve the results

quickly, short-term (5-min long) HRV measures are preferred as

offered in the Task Force [9].

If there is a strong correlation among variables, then the accuracy of the classier is getting worse, which is the so-called

curse of dimensionality [35]. After applying the HRN-based data

normalization method, average statistical signicance values are

drastically reduced (Table 2). Heart rate normalization seems to

remove the correlation among HRV measures slightly. Nonetheless, an optimal or sub-optimal feature selection algorithm may

lead to more higher accuracies in classiers.

Only three measures were found to show statistically signicant differences ( p 5% ) among 29 measures. These measures

were normalized LF and normalized HF from LS-based frequency

analysis and HF from wavelet entropy based frequency analysis.

118

vagal activities in the autonomous nervous system, this may

conclude that normalized calculations of these frequency components have signicant roles to discriminate whether CHF is systolic

or diastolic. Furthermore, LS and wavelet entropy methods may

give more statistically meaningful frequency-domain measures

because pre-processing steps such as re-sampling and detrending

may affect HRV measures [25].

The results, which are given in Tables 3 and 4, show that using

both MINMAX and HR normalization procedures improve the

performance of the classication. The maximum accuracy is found

to be 96.43% with both MINMAX and heart rate normalized features using a MLP classier. This shows that this classication

system can be used by physicians to detect systolic or diastolic CHF

patients from a ECG record easily. Nonetheless, there are only 30

participants in the study and this number is less than desired.

More patient data is needed to enhance the validity of this study.

In addition, HR normalization also improves the statistical

signicances in time-domain and non-linear HRV measures. This

indicates that the heart rate normalization methods improve the

discrimination capability of classiers.

In this study, only NN and MLP classiers are used to evaluate

the performance since these classication methods do not depend

on the data with any particular distribution. Using other classiers,

given in the literature related to machine learning, could further

improve the accuracy values.

Moreover, using long-term HRV measures in addition to the

short-term ones could also enhance the diagnostic ability of the

constructed classier systems. This is because the measures calculated from a 5-min HRV data do not reect the whole-day activity of the heart.

Conict of interest

None declared.

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Yalcin Isler (1971) received the B.Sc. degree in Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree in

Electronics and Communication Engineering, Suleyman Demirel University, Isparta,

Turkey, in 1996, and the Ph.D. degree in Electrical and Electronics Engineering,

Dokuz Eylul University, Izmir, Turkey, in 2009.

He worked as a lecturer in Burdur Vocational School of Suleyman Demirel

University (Burdur, 19932000), as a software engineer at the Department of

Research and Development in commercial companies (Izmir, 20002002), as a

research assistant in Bulent Ecevit University (Zonguldak, 20022003) and in

119

and Electronics Engineering of Bulent Ecevit University (Zonguldak, 20102012).

He has been working as an assistant professor with the Department of Biomedical Engineering in Izmir Katip Celebi University, Izmir, since 2012. His main

research interests are biomedical signal processing, medical device design,

computational neuroscience, pattern recognition, and embedded systems. He is

involved in several national projects on computer science in medicine and on

other elds that required designing electronic boards based on embedded

systems.

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