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A study on standard and atrial lead system for improved screening of P-wave
using random forest classifier

Conference Paper · November 2021

DOI: 10.1109/IBSSC53889.2021.9673216

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 A study on standard and atrial lead system for
improved screening of P-wave using random forest
classifier
N. Prasanna Venkatesh
Bio-signals and Medical Instrumentation Laboratory
Department of Biotechnology and Medical Engineering
National Institute of Technology Rourkela
2021 IEEE Bombay Section Signature Conference (IBSSC) | 978-1-6654-1758-7/21/$31.00 ©2021 IEEE | DOI: 10.1109/IBSSC53889.2021.9673216
Odisha, India
519bm6012@nitrkl.ac.in
Abstract—The challenging aspect of diagnosing atrial
arrhythmias is the accurate detection of P-wave. P-wave
visibility helps in better clinical decision-making and is
essential in detecting atrial arrhythmias. Improved screening
of P-wave requires improved recording or signal acquisition
methods. In this study, an Atrial Lead System (ALS) is
developed for improved recording of P-wave amplitude in
sinus rhythm volunteers. The ALS is compared with the
existing Standard Limb Lead (SLL) system for significant
changes in signal strength in bipolar and augmented unipolar
leads. The study developed a Random Forest (RF)
classification model to classify SLL and ALS ECG. The RF
model exhibited a 10-fold cross-validation accuracy of 0.92.
The sensitivity, precision, and F1 score of the RF model are
0.96, 0.91, and 0.92, respectively. The developed model predicts
the test data with an accuracy of 0.89 and a precision of 0.95
for ALS than SLL (0.85). The classification accuracy obtained
is mainly due to a greater difference in P-wave amplitude (µV)
between the leads. This difference is due to improved recording
of P-wave in ALS than SLL system. The study concludes that
the RF model automatically detects ALS for better
visualization of P-wave.
Keywords—Atrial activity, Atrial lead system, Classification,
P-wave amplitude, Random Forest model
I. INTRODUCTION
Worldwide Coronavirus diseases 2019 (COVID-19)
deaths are widely associated with Cardiac arrhythmias.
Retrospective analysis conducted in a recent worldwide
survey on COVID-19 associated arrhythmias documented
atrial fibrillation (AF), atrial flutter, supraventricular
tachycardia, and atrioventricular blocks as are most common
cardiac arrhythmias in COVID-19 deaths [1]. Among all
arrhythmias associated with COVID-19 deaths, the
occurrence of atrial arrhythmias is about 81.8% [1]. High
morbidity and mortality highlight the need for a greater
number of cardiologists in COVID-19 care [1]. Pitman et al.
[2], in their recent study, conclude that better P-wave
visibility may improve clinical decision-making, and it is
crucial in diagnosing atrial arrhythmias. However,
distinguishing the tiny and diagnostically significant P-wave
from background noise in all leads of a standard 12-lead
electrocardiogram [ECG] recording is a fundamental
challenge. Moreover, atrial activity is largely obscured by
dominant ventricular activity in standard ECG recordings
*Corresponding author: Dr. J. Sivaraman, Bio-signals and Medical
Instrumentation Laboratory, National Institute of Technology
Rourkela.
978-1-6654-1758-7/21/$31.00 © 2021 IEEE
Authorized licensed use limited to: NATIONAL INSTITUTE OF TECHNOLOGY ROURKELA. Downloaded on February 02,2022 at 05:23:32 UTC from IEEE Xplore. Restrictions apply.
J. Sivaraman* Member, IEEE
Bio-signals and Medical Instrumentation Laboratory
Department of Biotechnology and Medical Engineering
National Institute of Technology Rourkela
Odisha, India
jsiva@nitrkl.ac.in
[3]. P-wave detection accuracy on an ECG is important in
the detection of atrial arrhythmias [4]. Majority of AF
detection relay on R-R intervals, which causes false-positive
decisions in diagnosing atrial arrhythmias [5].
Einthoven first devised the electrode placement for
Standard Limb Lead (SLL) [6]. Unipolar limb leads and six
unipolar chest leads were later established by Wilson et al.
[7]. In order to boost the voltages recorded by unipolar limb
leads, Goldberger [8] devised augmented unipolar leads by
modifying Wilson’s central terminal. For better atrial
activity recording, several lead changes have been explored.
Z. Ihara et al. [9] created the atrialcardiogram (ACG) by
optimizing the conventional 12-lead ECG for monitoring
atrial activity with the same number of electrodes by
positioning the electrodes closer to the right and left atrium.
Sir Thomas Lewis was the first to propose a lead system
using electrodes in the second and fourth right intercostal
spaces to capture atrial activity during atrial arrhythmias
[10]. Petrėnas et al. [11] designed a lead system by adjusting
the Lewis lead electrode location, moving the electrode
from the fourth right intercostal space to the fifth right
intercostal space to eliminate motion artifacts and monitor
atrial arrhythmias during ambulation and named as modified
Lewis lead. The P-wave obtained from modified Lewis lead
has three times larger amplitude than the original Lewis
lead. Kennedy et al. [12] hypothesized that a P-lead created
from electrodes positioned on the right sternal clavicular
junction and seventh intercostal space over the left side of
the thorax in line with the costal margin outperforms by
increasing P-wave RMS (µV).
The disadvantages of the aforesaid leads include just
having a single bipolar lead with superior P-wave recording
but primarily suppressing R-peak. This is because the
above-discussed leads are placed closer proximity to the
atrium and towards the right side of the torso. According to
the study [12], a two-lead method is capable of maximizing
the signal strength during normal and pathological atrial
activation and is most beneficial for atrial arrhythmias. As a
result, the proposed research focuses on the Atrial Lead
System (ALS), a new reduced ECG lead system capable of
recording better P-wave amplitude in its unipolar and
bipolar leads. Since, ECG provides a record of the electrical
activity of a large mass of atrial and ventricular cells rather
than a single cell [13]. The ALS is optimized by aligning
bipolar leads with the heart’s interatrial and atrioventricular
 electrical conduction vectors. The earlier study [14] paper speed of 10 mm/mV and 25 mm/s. The ECG signal is
introduced the design of ALS leads and their electrode preprocessed and interpreted by an inbuilt Glasgow
placements for better P-wave amplitude recording. algorithm [16] in the ECG machine. The waveform
The novelty of the proposed study classifies the SLL and morphologies are shown in Fig. 2. Since the study focus on
ALS ECGs among sinus rhythm volunteers in normal atrial improved visualization of P-wave in all the ALS leads than
activation. The automatic detection and prediction of better- SLL leads. Only P-wave amplitude is considered from SLL
recording methods between SLL and ALS will help in the and ALS for statistical analysis and classification methods.
visualization and analysis of P-wave. P-wave amplitudes The statistical significance is calculated using Wilcoxon
signed-rank test, as the values reject normality in the
extracted from different bipolar and unipolar leads of SLL
Shapiro-Wilkinson test. Origin Pro, version 2020b of Origin
and ALS ECGs are considered as input features in a
Lab companies, was used to perform all statistical
Random Forest-based classifier. procedures.
II. METHODOLOGY
A. Study Design
Seventy-five sinus rhythm male volunteers, with an
average age of 25 ± 2.8 years, participated in this
experimental study. All of the participants were recruited
from the National Institute of Technology Rourkela and
given their informed consent to take part in the study.
Smokers, alcoholics, those with high blood pressure, people
with heart disease, and people who are on medication are all
excluded from the study [15].
B. Atrial Lead System
The electrode placement of the ALS is briefly discussed
as follows (Fig. 1). The electrodes for the ALS lead system
are placed over the torso. Electrode 1 is placed on the
manubrium part of the sternum below the jugular notch.
Electrodes 2 and 3 are positioned over the costal margin on
the right and left seventh intercostal spaces. The lead AL-I is
obtained from electrodes 1 and 2. Lead AL-II is derived from
electrodes 1 and 3. The leads AL-I and AL-II are designed to (a)
capture heart interatrial conduction and atrioventricular
conduction by a parallel connection. AL-III is formed as a
resultant of electrodes 2 and 3. The augmented unipolar leads
aV1, aV2, and aV3 are formed from electrodes 1, 2, and 3.
The polarity of electrode 1 is negative, and electrodes 2 and
3 are positive. The reference electrode is placed in the right
ankle.

(b)
Fig. 1. Atrial lead system with electrode placement.

C. Data Acquisition and Statistical analysis
ECG recording is done with the SLL and ALS lead
systems using the Mindray Beneheart R12 ECG machine.
Unipolar precordial leads are excluded in this comparative
study. The machine has a frequency response of 0.05 to 150
Hz with a sampling frequency of 1000 samples/second. All
the data are recorded for 10-sec duration in supine rest
position. The electrodes used are pre-gelled disposable
surface electrodes and suction electrodes placed using
conductive electrolytic gel. The data are recorded with the
Fig. 2. ECG waveform morphology of (a) Standard limb lead system and (b)
Atrial lead system recorded from sinus rhythm subjects with the paper speed
of 10 mm/mV and 25 mm/s.
D. Feature set
The feature set considered for classification consists of
P-wave amplitudes in SLL and ALS ECG lead systems.
Features of SLL and ALS include P-wave amplitude levels
in bipolar and unipolar augmented leads; the SLL and ALS
were considered as classes. The unit of P-wave amplitude
considered from all the leads are in µV. Table I, shows the

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 P-wave amplitudes considered from three bipolar and three = (2)
augmented unipolar leads of SLL and ALS leads systems
for the design and development of the machine learning
+
model. The study involves the improved recording of P- "## #$ = (3)
wave amplitude in the ALS lead system to showcase the role + + +
of better visualization of P-wave in automatic detection and
diagnosis of atrial activity. The dataset consists of 150 '( ) $= (4)
samples of P-wave amplitude (µV) values with 75 samples +
of SLL and 75 samples of ALS. The value of SLL and ALS
are labeled as class 0 and class 1.
(# = (5)
+
TABLE I. SIGNIFICANCE OF P-WAVE AMPLITUDES IN SLL
AND ALS ELECTROCARDIOGRAMS
(# ∗ '( ) $
Measurements Leads Standard Leads Atrial p- 1 # ( =2∗ - . (6)
(# + '( ) $
Limb Lead value*
Lead System Where TN is True Negative, TP is True Positive, FN is False
Negative, and FP is False Positive.
(SLL) (ALS)
Mean ± Mean ± III. RESULTS
CI CI Fig. 3 depicts the detailed representation of box and
I 87 ± 8 AL-I 174 ± 18 <0.05 whisker plots of P-wave amplitude (µV) in bipolar and
augmented unipolar leads of SLL and ALS lead systems.
II 139 ± 10 AL-II 187 ± 16 <0.05
The minimum, median and maximum values of bipolar leads
P-wave III 78 ± 11 AL-III 40 ± 5 <0.05 AL-I, AL-II, and AL-III are 80, 146, and 341 µV; 85, 172,
amplitude (µV)
aVR 110 ± 7 aV1 184 ± 19 <0.05 and 335 µV; and 4, 35, and 82 µV respectively. The
minimum, median and maximum values of corresponding
aVL 46 ± 8 aV2 73 ± 11 <0.05
leads like leads I, II, and III in SLL are 8, 41, and 101 µV;
aVF 102 ± 11 aV3 106 ± 8 >0.05 60, 129, and 198 µV; and 8, 72, and 171 µV respectively.
P-wave NA 99 ± 4 NA 91 ± 4 >0.05 The augmented unipolar leads like aV1, aV2, and aV3 of
duration (ms) ALS have the minimum, median and maximum values of 99,
PR-interval NA 144 ± 4 NA 142 ± 6 >0.05 159, and 336 µV; 10, 58, and 175 µV; and 50, 108, and 189
(ms) µV respectively. The similar augmented unipolar leads aVR,
CI – Confidence Interval (95%); * Wilcoxon signed-rank test
aVL, and aVF in SLL have the minimum, median and
maximum values of 50, 113, and 178 µV; 7, 41, and 101 µV;
E. Random Forest Claasifier and 11, 94, and 185 µV respectively.
The Random Forest (RF) classifier is a tree-based Table I shows the P-wave amplitude feature in the
learning technique that uses an ensemble of trees. Ensemble bipolar and the augmented unipolar leads of the SLL and
algorithms combine several methods, either of the same or ALS ECG system. P-wave duration (ms) and PR-interval
distinct types, to classify objects. A set of decision trees from (ms) are also shown. The table demonstrates the statistical
a randomly selected subset of the training data is used by the significance between all the considered features of SLL and
RF Classifier. It combines the votes from various decision ALS. The time-domain parameters like P-wave duration and
trees to determine the test object’s final class. The Gini index PR-interval have no significant changes (p > 0.05).
formula is frequently used by the RF to choose the nodes on The amplitude parameters like P-wave amplitude have
the decision tree branch. This formula combines class and significant changes in the bipolar and unipolar leads between
probability to calculate the Gini of each branch on a node, SLL and ALS (p < 0.05) other than aVF and aV3 (p > 0.05).
allowing you to see which branch is more likely to occur.
Fig. 4 shows the confusion matrix for the test data after
10-fold cross-validation. It consists of 30 % of the whole
=1− ( ) (1) dataset that includes 46 samples. The remaining 70 % of the
dataset is training data and are about 104 samples. Among 46
Here, the relative frequency of the class in the dataset is samples, 23 are SLL ECG samples, and the remaining 23 are
represented by pi, while the number of classes is represented ALS ECG samples. The samples that are correctly classified
by C. as SLL ECG are 22, and ALS ECG is 19. The predicted
classes correspond very well with the true classes; this is
F. Performance Analysis indicated by the low number of false classifications.
The developed RF model was analyzed based on Fig. 5 illustrates the receiver operating characteristic
parameters from classification and prediction. (ROC) curve. The area under the curve (AUC) is typically
The parameters are accuracy, sensitivity, recall, precision, represented by a ROC curve. It's the line drawn between the
and F1 score, and their equations are displayed as follows. true positive rate (sensitivity) and the false-positive rate.
The parameters are calculated from the confusion matrix. The AUC in ROC curve for the proposed RF model in SLL
The confusion matrix has the following, (class 0) is 0.98 and for ALS (class 1) is 0.98. The AUC in
micro-average and macro-average ROC curves for the
developed model are 0.98 and 0.99.

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 Fig. 6, shows the validation curve of the proposed RF
model. The graph represents the accuracy score of training
and 10-fold cross-validation. Fig. 6, shows the accuracy of
the model for the test set against the maximum depth of the
actual estimator. The curve shows the accuracy of the
developed model after 10-fold cross-validation is 0.9218.
Table II divulges the information of the RF model's
classification report. The classification report states that SLL
ECG has precision, sensitivity, and F1 score of about 0.85,
0.96, and 0.90, respectively. A total of 23 SLL ECG samples
and 23 ALS ECG samples were received for testing the RF
model. The precision, recall, and F1 score obtained by the
model to classify ALS are 0.95, 0.83, and 0.88.

Fig. 5. ROC curves of random forest model

Fig. 3. Distribution of P-wave amplitude in SLL and ALS ECG leads

Fig. 6. Validation curve for random forest model

TABLE II. CLASSIFICATION REPORT OF RANDOM FOREST IV. DISCUSSION

MODEL
The proper characterization of atrial and ventricular
arrhythmias depends on the recognition of P-waves [17].
Random Forest model Classification report
The ALS discussed in this study shows the clinically
Precision Sensitivity F1 Support important P-wave with improved amplitude. Amplitude and
SLL 0.85 0.96 0.90 23 duration are diagnostic morphological features of ECG. The
ALS 0.95 0.83 0.88 23 study analyzes and compares the morphological feature of
atrial activity between the two different recordings of sinus
rhythm ECGs of the same volunteers considered. The
methods used for this comparative study are SLL and ALS.
Since the study focuses on atria, the P-wave morphological
improvement is considered. From Fig. 2, the P-wave in ALS
leads occupies 2 to 3 mm of values in the y-axis (mV), but in
SLL, it is 0.5 to 1 mm at the standard paper speed. This
justifies the visual changes in signal strength of ECG wave
morphologies between the bipolar and augmented unipolar
leads of SLL and ALS and stands as a solutions to the
problem stated in [2], as P-wave visibility improves clinical
decision-making.
P-wave amplitudes were independent predictive factors
for AF [18]. So, the statistical significance of the
improvement in P-wave is studied between the SLL and
ALS. The P-wave amplitude in ALS Leads AL-I, AL-II,
aV1, and aV2 has significantly greater amplitude than SLL
leads I, II, aVR, and aVL (p < 0.05). Lead aV3 and aVF have
no significant changes, but there are incremental changes in
Fig. 4. Confusion matrix of random forest model. the mean amplitude of aV3 than aVL. Since the study
involves only the sinus rhythm volunteers, there are no

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 significant changes in the temporal parameters of atria (i.e.)
P-wave duration and PR-interval. This was also confirmed in
previous studies [19-22] that changes in electrode placements
will have no change in temporal parameters in ECG when
considering healthy subjects.
The application of P wave morphological analysis will
improve the detection of an aberrant electrical substrate in
the atrial myocardium as well as the localization of ectopic
atrial beats. A hardware setup that allows for high-quality
signal capture will be required for a detailed investigation of
the low voltage P wave [23]. For this, machine learning
based automated classification and detection of improved
P-wave among the SLL and ALS lead system was
developed. The model developed is based on RF
classification algorithm. The dataset is trained with the RF
algorithm to develop the RF model. The model outperformed
in classifying the SLL and ALS ECG by showing an
accuracy of 0.92. The AUC of the developed RF model for
class 0 and class 1 is about 0.98, which is detailed in the
ROC plot. This higher AUC justifies that the ability and
performance of the model in classifying SLL and ALS. The
developed RF model predicts the ALS from the test data with
an accuracy of 0.89. The confusion matrix shows the true
classification and false classification results of SLL and
ALS. The classification of ECG based on morphological
features using the cat-boost model concludes P-wave (µV) is
the prominent feature for accurate classification of sinus
rhythm, sinus tachycardia, and atrial tachycardia [24]. The
RF model shows the validation accuracy score of about 0.92
after 10-fold cross-validation of the train and test dataset.
The classification report of the RF model shows the
precision, sensitivity, and F1-score of the developed model
for classifying the SLL and ALS. The precision of ALS
(0.95) is greater than SLL (0.85), and this result showcases
the detection of significant improvement in P-wave
amplitude in ALS by the developed RF model.
P-wave amplitude in the inferior leads is the strongest
independent predictor of pulmonary mortality that exceeds
all other ECG risk markers [25]. The developed leads AL-I
and AL-II are similar to the inferior leads and hence show
higher signal strength. The lead AL-III is the resultant lead
and has lesser amplitude. Also, the lead is perpendicular to
the heart’s electrical conduction vector. A recent study [26]
developed a 2D-CNN model to classify the normal and heart
failure patients for intelligent screening of systolic heart
failure used the entire 12 lead ECG signal as the feature. The
present study also uses specifically the P-wave (µV) in 6
bipolar and augmented unipolar leads of the ECG signals as
a feature for the developed model.
V. CONCLUSION
In the proposed study, the classification of SLL and ALS
ECG is performed for automatic detection of ALS for the
improved recording of P-wave. The developed RF model has
a classification accuracy of about 0.92 and the prediction
accuracy of about 0.89. The model also has the highest
precision of 0.95 for ALS. This highest classification,
prediction accuracy, and precision of the model state a larger
difference in P-wave amplitude between SLL and ALS
among sinus rhythm volunteers. This difference is due to the
improvement in signal strength in terms of amplitude
between SLL and ALS. Thus, the improved amplitude of the
P-wave supports automated classification and prediction.
This significant enhancement in signal strength is also
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proven in the graphical representation and statistical plots.
The study lights only on atrial activity and has no
information about the ventricular activity. The study
concludes that better examination or screening of P-wave is
prominent in ALS than SLL ECG lead system.
ACKNOWLEDGMENT
The authors acknowledge the support from the Ministry
of Education, Government of India. The present study was
supported by financial grants from the Science and
Engineering Research Board (SERB), Department of Science
and Technology (DST), Government of India
(EEQ/2019/000148).
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