4/16/23, 10:14 AM Novel AI-based HRV analysis (NAIHA) in healthcare automation and related applications - ScienceDirect

Journal of Electrocardiology
Volume 79, July–August 2023, Pages 112-121

Novel AI-based HRV analysis (NAIHA) in healthcare automation and

related applications
L.R. Rahul a, Rahuldeb Sarkar b c, Arnab Sengupta d, B. Sandeep Chandra e f, Soumya Jana a

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Abstract

Background
Heart rate variability (HRV) analysis computed on R-R interval series of ECG records with heavy
burden of ectopic beats or non-sinus rhythm can significantly distort HRV parameters and hence
clinically ineligible for HRV analysis. Yet, existing algorithmic methods of HRV analysis do not check
such eligibility and require manual identification of eligible window (portion of ECG record) to ensure
reliability.

Objective
We aimed to propose a robust algorithm with a sliding window feature to automate the identification
of an eligible window, if available, which compute HRV parameters within that window obviating
manual input.

Methods
The proposed algorithm classifies each window as either eligible or ineligible. With a window
classified eligible, we stop sliding through the record, otherwise we move to the next window and
repeat the eligibility identification process, until either an eligible window is found, or all windows
are exhausted.

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4/16/23, 10:14 AM Novel AI-based HRV analysis (NAIHA) in healthcare automation and related applications - ScienceDirect

Results
When evaluated on random subset of 100 records from MIMIC-III waveform database, the proposed
algorithm excluded every ineligible record, and missed only 1.25% of eligible ones. The HRV
parameters computed using proposed method closely approximated the standard HRV analysis with
Pearson correlation coefficients (ideally one) and fractions of variance unexplained (ideally zero)
ranging from 96.3% to 99.8% and 0.34% to 7.43%, respectively.

Conclusions
When translated into practice, proposed algorithm will reduce clinicians'' burden without
compromising the accuracy of HRV analysis, potentially leading to its wider adoption.

Introduction

Heart rate variability (HRV) analysis, providing insights into autonomic nervous system (ANS) activity
and cardiac health [[1], [2], [3]], has emerged as a significant area of physiological research in recent
decades. A high HRV tends to correspond to greater cardiovascular fitness and resilience to stress [4],
while a low HRV correlates with an increased risk of cardiovascular disease and mortality post
myocardial infarction [[5], [6], [7]]. In acute care settings, HRV may provide additional diagnostic and
prognostic information at the bedside when monitored alongside regularly used physiological
variables. In exercise physiology, HRV can potentially be used as biofeedback as it tracks time course of
training adaptation/maladaptation [8,9]. Attempts at incorporating HRV in lifestyle devices such as
fitness bands are also ongoing [10,11].

According to standard HRV analysis protocol, one computes multiple statistics measuring fluctuations
in time intervals between successive cardiac beats, usually based on electrocardiogram (ECG) records
[1]. In this regard, only R-R intervals (RRI) corresponding to sinus beats should be considered, as non-
sinus (ectopic) beats are not subject to ANS in a way the sinus rhythm is [1,13,14]. Therefore,
traditional pulse-beat-based algorithms, which correct abnormal RRI without regard to the ECG
morphology, could be unreliable if there is a heavy burden of ectopic beats or non-sinus rhythm. [12].
Furthermore, while a number of high-performance R-peak detectors and heart beat classifiers have
been reported [[15], [16], [17], [18]], their specific efficacy in preventing errors in HRV analysis
resulting from sinus beats, which are either missed (with aberrant morphologies) or misidentified,
has not yet been validated.

RRI correction in order to meet certain consistency criteria traditionally involves deletion and
interpolation [30]. Advancements including comparing-merging [22], predictive autocorrelation [23],
nonlinear predictive interpolation [24], detrending using smoothness prior [25], wavelet based trend
removal via nonlinear filtering [26], and autoregressive (AR) model based techniques [[19], [20], [21]],
have since been reported. However, this approach of RRI series correction suffer from fundamental
limitations. First, given heavy burden of ectopics, such correction tends to distort HRV parameters
[[30], [31], [32], [33], [34]]. Second, a consistent RRI series with underlying (and hence undetected)

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4/16/23, 10:14 AM Novel AI-based HRV analysis (NAIHA) in healthcare automation and related applications - ScienceDirect

morphological artifacts may also compute HRV parameters incorrectly, with the possibility that HRV
analysis might then be performed on ineligible records (e.g., those with atrial fibrillation). Finally,
recent commercial tools based on aforesaid methods tend to perform HRV analysis on a user-specified
window in a record, but lack the functionality of automatically selecting an eligible window [[27],
[28], [29]]. In short, automated HRV analysis has considerable room for improvement.

Against this backdrop, we propose NAIHA, a novel artificial intelligence (AI) based HRV analysis
algorithm, which analyzes the morphology of individual as well as sequence of beats using a two-
stage deep learning (DL) classifier, and subsequently searches over successive time intervals to identify
eligible windows, followed by computing the HRV parameters on RRI series with abnormal RRIs
excluded. Accuracy of eligible window identification by NAIHA was tested on the publicly available
MIMIC-III (Medical Information Mart for Intensive Care) waveform database [35], and the HRV
parameters computed for such window were found to closely approximate corresponding standard
estimates.

Section snippets

Materials and methods

Standard HRV analysis on an ECG record involves three tasks: (i) identification of an eligible window
(with 5% burden of non-sinus beats or less); (ii) removal of non-sinus RRIs; and (iii) computation of
HRV parameters based on normal RRIs (NNIs). In standard HRV analysis, eligible window identi-
fication and elimination of abnormal RRIs were done manually, requiring a significant amount of time
and effort on the part of clinicians, especially when working with a large patient population. The…

Results

We consider four 5-min ECG windows from Dataset-6, highlight in Fig. 3A morphological variations
by suitably zooming in (top row), and depict the entire RRI series (bottom row). Per standard
protocol, the first window (Fig. 3A(a)) is eligible for HRV analysis with the non-sinus beat burden less
than 5%. Here, any existing RRI correction techniques should be adequate, and produce reliable HRV
analysis. In contrast, on the next two windows (Fig. 3A(b) and Fig. 3A(c)), which are ineligible with…

Discussion

In this study, we developed an algorithm NAIHA that accurately finds the first 5-min window eligible
for HRV analysis from a 30-min ECG record and calculates HRV parameters with precision. The HRV
parameters computed by the proposed algorithm closely matched those obtained from standard HRV
analysis, with Pearson correlation coefficients (ideally, 100%) ranging from 96.3% to 99.8%, and fraction
of variance unexplained (ideally, zero) ranging from 0.34% to 7.43%. When tested on a random
subset…

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4/16/23, 10:14 AM Novel AI-based HRV analysis (NAIHA) in healthcare automation and related applications - ScienceDirect

Conclusion

We have shown through NAIHA that it is possible to present a length of ECG recording, and automate
the process of identifying a window suitable for HRV analysis with low false negative and false
positive rates, as well as computing HRV parameters, potentially facilitating their wider use.…

Author contributions

R.L.R. developed the algorithms, performed the experiments, prepared an initial draft and revised it
several times based on inputs. R.S. performed data annotation and provided clinical inputs. A.S. and
B.S.C. contributed to the study design as well as data interpretation, and provided critical review.

S.J. and R.S. provided overall supervision, approved study design, algorithms and results, and finalized
the manuscript.…

Funding

This research has been partially supported by Grant No. 4(3)/2020-ITEA of the Ministry of Electronics
and Information Technology, Government of India.…

Declaration of Competing Interest

No potential conflict of interest was reported by the authors.…

References (42)

Pandelis Perakakis
KARDIA: a Matlab software for the analysis of cardiac interbeat intervals
Comput. Methods Prog. Biomed. (2010)

M.P. Tarvainen et al.

Kubios HRV–heart rate variability analysis software
Comput. Methods Programs Biomed. (2014)

R.A. Thuraisingham
Preprocessing RR interval time series for heart rate variability analysis and estimates of
standard deviation of RR intervals
Comput. Methods Prog. Biomed. (2006)

F. Zhang et al.
Bioelectric signal detrending using smoothness prior approach
Med. Eng. Phys. (2014)

https://www.sciencedirect.com/science/article/abs/pii/S0022073623000602 4/7
4/16/23, 10:14 AM Novel AI-based HRV analysis (NAIHA) in healthcare automation and related applications - ScienceDirect

U.R. Acharya et al.

A deep convolutional neural network model to classify heartbeats
Comput. Biol. Med. (2017)

C. Yu et al.
A method for automatic identification of reliable heart rates calculated from ECG and PPG
waveforms
J. Am. Med. Inform. Assoc. (2006)

M.Ø. Andersen et al.

Heart rate variability as assessed with long-term continuous cardiac Moni- toring in
pulmonary hypertension
J. Am. Coll. Cardiol. (2020)

T.E. Adler et al.

Heart rate variability is reduced 3-and 6-months after hospitalization for covid-19 infection
J. Am. Coll. Cardiol. (2021)

A.H. Kemp et al.

The relationship between mental and physical health: insights from the study of heart rate
variability
Int. J. Psychophysiol. (2013)

C. Hayward et al.
Heart rate variability, assessed in one minute windows, provides insight into the time
course of changes in autonomic nervous system activity
J. Am. Coll. Cardiol. (2015)

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