Thesis. 1977. B.S.--Massachusetts Institute of Technology. Dept. of Electrical Engineering and Computer Science. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND ENGINEERING. / Bibliography: leaf 50. / B.S.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 5 uppsatser.

This project deals with anatomy and electrophysiology of heart. It describes the structure of cardiac muscle, mechanism of myocard's contraction, heart work, the origin and registration of electric signals of heart – electrocardiogram (ECG) and vectorcardiogram (VCG). Part of the work is design and creation of a software application for calculation and graphical presentation of vectorcardograms, useful for experimental data available on ÚBMI VUT in Brno.

<p>This study evaluated the use of multi-lead ST-monitoring in the early assessment of patients with suspected or confirmed unstable coronary artery disease (UCAD).</p><p>At continuous 12-lead ECG (c12ECG), the definition of an ischemic episode as a transient ST-deviation ¡Ý0 for at least 1 minute resulted in a good observer agreement (kappa=0.72) and an acceptable incidence of postural ST-changes.</p><p>When c12ECG was performed from admission and for 12 hours in 630 patients with suspected UCAD, 16% had ischemic episodes. At 30 days, patients with episodes had a higher risk of cardiac death or myocardial infarction (MI) (10% vs. 1.5%). In a multivariate analysis, troponin T¡Ý0.10¦Ìg/l and presence of ischemic episodes were independent predictors of cardiac death or MI. When ST-monitoring and troponin T status were combined, patients could be divided into a low-, intermediate-, and high-risk group with 1%, 4% and 12% risk for cardiac death or MI at 30 days of follow up.</p><p>As a part of a multicenter trial, including patients with UCAD, 1016 patients underwent ST-monitoring with c12ECG or continuous vectorcardiography (cVCG). Ischemia was detected in 32% and 35%, respectively. When the groups with ischemia were compared, the groups were similar with respect to several clinical variables. Thus, these methods identify the same high-risk population.</p><p>Of the 629 patients treated non-invasively with extended treatment of low-molecular- weight heparin (LMWH) or placebo, 34% had ischemic episodes. In this group at 3 months, patients administered LMWH had a significantly lower risk of death, MI, or revascularization than patients treated with placebo (35.2% vs. 53.4%). In patients without transient ischemic episodes, the outcome in the LMWH and placebo group was similar.</p><p>Thus, multi-lead monitoring provides important prognostic information early after admission in this population, and seems to identify patients who benefit most from extended antithrombotic treatment.</p>

This study evaluated the use of multi-lead ST-monitoring in the early assessment of patients with suspected or confirmed unstable coronary artery disease (UCAD). At continuous 12-lead ECG (c12ECG), the definition of an ischemic episode as a transient ST-deviation ¡Ý0 for at least 1 minute resulted in a good observer agreement (kappa=0.72) and an acceptable incidence of postural ST-changes. When c12ECG was performed from admission and for 12 hours in 630 patients with suspected UCAD, 16% had ischemic episodes. At 30 days, patients with episodes had a higher risk of cardiac death or myocardial infarction (MI) (10% vs. 1.5%). In a multivariate analysis, troponin T¡Ý0.10¦Ìg/l and presence of ischemic episodes were independent predictors of cardiac death or MI. When ST-monitoring and troponin T status were combined, patients could be divided into a low-, intermediate-, and high-risk group with 1%, 4% and 12% risk for cardiac death or MI at 30 days of follow up. As a part of a multicenter trial, including patients with UCAD, 1016 patients underwent ST-monitoring with c12ECG or continuous vectorcardiography (cVCG). Ischemia was detected in 32% and 35%, respectively. When the groups with ischemia were compared, the groups were similar with respect to several clinical variables. Thus, these methods identify the same high-risk population. Of the 629 patients treated non-invasively with extended treatment of low-molecular- weight heparin (LMWH) or placebo, 34% had ischemic episodes. In this group at 3 months, patients administered LMWH had a significantly lower risk of death, MI, or revascularization than patients treated with placebo (35.2% vs. 53.4%). In patients without transient ischemic episodes, the outcome in the LMWH and placebo group was similar. Thus, multi-lead monitoring provides important prognostic information early after admission in this population, and seems to identify patients who benefit most from extended antithrombotic treatment.

Introduction. Multiple clinical methods for detecting myocardial ischemia are utilised in the hospital setting each day, but there is uncertainty about their diagnostic accuracy. In the operating room, multiple methods may be employed, while in the CCU advanced electrophysiological (ECG) techniques for myocardial ischemia detection, and in particular, ST segment analysis, are common. Vectorcardiography (VCG) is one form of ECG. Several conditions other than ischemia may cause marked ST changes, which can impair the process of diagnosis of clinical ischemia. Elevated HR is one of these factors, which is studied here. The hypotheses were about concordance of different methods to detect ischemia, and relation of ECG ST levels to HR with and without myocardial ischemia. Methods. Study I. Anesthetised vascular surgical patients with coronary artery disease were studied during the start of anesthesia and surgery: ECG, hemodynamic, mechanical, and metabolic parameters were measured and categorised as positive or negative with reference to a specific definition of myocardial ischemia. Study II. Awake patients with no ischemic heart disease were paced in graded steps, and VCG ST analyses were performed. Study III. Anesthetised pigs were studied for local metabolic and VCG ST changes related to controlled HR levels and transient coronary occlusion. Study IV. Thirty five anesthetised coronary artery disease (CAD) patients and ten non-CAD patients were paced at controlled levels, and great coronary artery vein (GCV) lactate measurement was used to determine presence or absence of myocardial ischemia. The CAD patients were paced up to HR levels where myocardial ischemia could be confirmed. The relation of HR-related VCG ST levels to presence or absence of ischemia was analysed. In Studies II,, III, and IV the ST vector magnitude (ST-VM), the change from baseline in ST-VM (STC-VM), and the vector angle change from baseline (STC-VA) were analysed for each step. Results. Study I. Poor concordance was demonstrated for positive events (presumed myocardial ischemia) between the hemodynamic, ECG, mechanical, and metabolic detection methods. Study II. STC-VM but not ST-VM levels demonstrated HR-related increases in the presumed absence of myocardial ischemia in 18 awake subjects. J point time to ST measurement did not affect the response of VCG ST to HR. Study III. STC-VM levels showed HR-related increases in the absence of ischemia (tested by local metabolic observations). VCG ST parameters responded positively to transient regional ischemia. Study IV. CAD patients, which demonstrated a clear pattern of onset and progress of ischemia during pacing, were further analysed for the relation of VCG ST level to ischemia. Sensitivity and specificity of STC-VM levels were described by ROC analysis for a range of STC-VM levels. Conclusions. Concordance of different measures for detection of onset of myocardial ischemia is difficult to assess in the absence of a very reliable reference method. The contribution of HR and ischemia to VCG ST levels were estimated in study subjects. HR-related increases in STC-VM occur in the absence of ischemia. HR levels need to be considered when interpreting STC-VM as a diagnostic test for ischemia. Further study is needed to establish criteria that take into account multiple clinical factors in order to improve the predictive value of our tests for myocardial ischemia.

Abstract Based on experimental studies, heterogeneous ventricular repolarization has been suggested to predispose to the onset of life-threatening ventricular arrhythmias and subsequent studies in various patient populations have associated it with poor clinical outcome. The aim of this study was to assess the dynamics of ventricular repolarization from electrocardiogram (ECG) during a standard exercise stress test with techniques based on principal component analysis, and to investigate whether they would yield valuable prognostic information on cardiac mortality and sudden cardiac death. Exercise ECG recordings from 40 healthy men and women were analyzed in order to establish normal dynamics and rate-dependence for the spatial QRS/T angle and total cosine R to T (TCRT), which reflects the spatial deviation between the depolarization and repolarization wave-fronts. Subsequently, exercise ECG recordings from 20 patients with previous myocardial infarction (MI) were compared with 20 controls in order to assess the modulation of previous MI on the dynamics of TCRT. The prognostic value of abnormal dynamics and rate-dependence of TCRT and spatial QRS/T angle were assessed in 1,297 patients referred to a clinically indicated exercise stress test. The spatial QRS/T angle and TCRT were found to be significantly rate-dependent during both exercise and recovery periods as TCRT and the cosine of the spatial QRS/T angle decreased at higher heart rates (HR), indicating increase in the global heterogeneity of the ventricular repolarization. In the post-MI group, the dynamics of TCRT were impaired with a significantly lower rate-dependence in contrast to the healthy and control groups. In the study cohort, impaired rate-dependence of TCRT during both exercise and recovery periods was an independent predictor of cardiac and sudden cardiac death during the follow up of the study. Similarly, reduction of the area between the exercise and three-minute recovery TCRT/HR curves was associated with an increased risk of cardiac and sudden cardiac death. In conclusion, dynamics and rate-dependence of TCRT and spatial QRS/T angle are able to discriminate subjects with an increased risk of cardiac and sudden cardiac death. Reduced rate-dependence of TCRT during exercise and recovery periods, as well as decreased exercise-recovery hysteresis of TCRT, are significant predictors of cardiac and sudden cardiac death. / Tiivistelmä Sydämen kammioiden poikkeavan palautumisen on kokeellisissa tutkimuksissa havaittu altistavan kammioperäisille rytmihäiriöille. Lisäksi, useat tutkimukset erilaisissa potilasaineistoissa ovat osoittaneet sen olevan yhteydessä heikkoon kliiniseen ennusteeseen. Tämän työn tarkoituksena oli analysoida sydämen kammioiden repolarisaation dynamiikkaa sydänsähkökäyrästä (EKG) rasituskokeen aikana pääkomponenttianalyysiin perustuvilla menetelmillä sekä tutkia, ennustavatko uudet muuttujat sydänperäistä kuolemaa tai sydänperäistä äkkikuolemaa. Neljänkymmenen terveen miehen ja naisen rasitus-EKG:t analysoitiin depolarisaatio- ja repolarisaatioaaltojen välistä avaruudellista kulmaa kuvaavan ’total cosine R to T’:n (TCRT) sekä kolmiulotteisen QRS/T-kulman dynamiikan sekä sykeriippuvuuden normaaliarvojen määrittämiseksi. Lisäksi, vertailtiin 20 sydäninfarktin sairastaneen sekä 20 kontrollipotilaan rasitusmittauksia aiemman infarktin TCRT:n dynamiikkaan sekä sykeriippuvuuteen aiheuttaman modulaation määrittämiseksi. Muuttujien poikkeavan dynamiikan ennustearvoa testattiin 1297 rasitus-EKG-mittaukseen lähetteen saaneella potilaalla. Sekä TCRT että avaruudellisen QRS/T-kulman kosini olivat molemmat erittäin sykeriippuvaisia sekä rasituksessa että palautumisessa. Molemmat muuttujat pienenivät sykkeen (HR) kasvaessa, osoittaen kammioiden repolarisaation heterogeenisyyden kasvua korkeammilla syketaajuuksilla. Sydäninfarktin sairastaneilla potilailla muuttujien dynamiikka ja sykeriippuvuus olivat heikentyneitä. Kohorttiaineistossa heikentynyt sykeriippuvuus sekä rasituksen että palautumisen aikana ennustivat myöhempää sydänperäistä kuolemaa sekä sydänperäistä äkkikuolemaa itsenäisesti. Vastaavasti, rasituksen ja kolmen minuutin palautumisen aikaisten TCRT/HR kuvaajien väliin jäävän pinta-alan pienentyminen oli yhteydessä korkeampaan sydänperäisen kuoleman sekä sydänperäisen äkkikuoleman riskiin. Kammioiden repolarisaation dynamiikkaa kuvaavat muuttujat pystyvät erottelemaan potilaat, joilla on korkeampi riski kokea sydänperäinen kuolema tai sydänperäinen äkkikuolema. Poikkeavan alhainen sykeriippuvuus rasituksen ja palautumisen aikana sekä alentunut rasituksen ja palautumisen välinen hystereesi olivat merkittäviä sydänperäisen kuoleman sekä sydänperäisen äkkikuoleman ennustajia.

En dépit du développement rapide de la médecine, les maladies cardiovasculaires restent la première cause de mortalité dans le monde. En France, chaque année, plus de 50 000 personnes meurent subitement en raison d'arythmies cardiaques. L'identification des patients à risque élevé de décès soudain est toujours un défi. Pour détecter les arythmies cardiaques, actuellement Holter est généralement utilisé pour enregistrer les signaux électrocardiogramme (ECG) à 1~3 dérivations pendant 24h à 72h. Cependant l'utilisation de Holter est limitée parmi la population en raison de son encombrement (pas convivial) et de son coût. Un Holter mono puce portable nommé SoC-Holter qui permet d'enregistrer 1 à 4 dérivations est introduit. Le déploiement d'un réseau de capteurs sans fil exige que chaque SoC-Holter soit peu encombrant et peu cher, et consomme peu d’énergie. Afin de minimiser la consommation d'énergie et le coût du système, la technologie Complementary Metal Oxide Semiconductor (CMOS) (0.35μm) est utilisée pour la première implémentation de SoC-Holter. Puis une nouvelle méthode de détection basée sur Acquisition Comprimée (CS) est introduite pour résoudre les problèmes de consommation d'énergie et de capacité de stockage de SoC-Holter. Le principe premier de cette plate-forme est d'échantillonner les signaux ECG sous la fréquence de Nyquist ‘sub-Nyquist’ et par la suite de classer directement les mesures compressées en états normal et anormal. Minimiser le nombre de fils qui relient les électrodes à la plate-forme peut rendre l’utilisateur de SoC-Holter plus confortable, car deux électrodes sont très proches sur la surface du corps. La différence ECG enregistrée est analysée à l'aide de Vectocardiogramme (VCG). Les résultats expérimentaux montrent qu'une approche intégrée, à faible coût et de faible encombrement (SoC-Holter) est faisable. Le SoC-Holter consomme moins de 10mW en fonctionnement. L'estimation des paramètres du signal acquis est effectuée directement à partir de mesures compressées, éliminant ainsi l'étape de la reconstruction et réduisant la complexité et le volume des calculs. En outre, le système fournit les signaux ECG compressés sans perte d'information, de ce fait il réduit significativement la consommation d'énergie pour l'envoi de message et l’espace de stockage mémoire. L'effet de placement des électrodes est évalué sur la QRS complexe lorsqu'il a enregistré avec deux électrodes adjacentes. La méthode est basée sur l'algorithme de ‘QRS-VCG loop alignment’. La méthode moindre carré est utilisée pour estimer la corrélation entre une boucle VCG observée et une boucle de référence en respectant les transformations de rotation et la synchronisation du temps. Les emplacements d'électrodes les moins sensibles aux interférences sont étudiés. / According to the figures released by World Health Organization (WHO), cardiovascular disease is the number one cause of death in the world. In France every year more than 50,000 people die suddenly due cardiac arrhythmias. Identification of high risk sudden death patients is still a challenge. To detect cardiac arrhythmias, currently Holter is generally used to record 1~4 leads electrocardiogram (ECG) signals during 24h to 72h. However the use of Holter is limited among the population due to its form factor (not user-friendly) and cost. An integrated single chip wearable Holter named SoC-Holter that enables to record 1 to 4 leads ECG is introduced. Deployment of wireless sensor network requires each SoC-Holter with less power consumption, low-cost charging system and less die area.To minimize energy consumption and system cost, Complementary Metal Oxide Semiconductor (CMOS) technology (0.35μm) is used to prototype the first implementation of SoC-Holter. Then a novel method based on Compressed Sensing (CS) technique is introduced for solving the problems of power consumption and storage capacity of SoC-Holter. The main principle underlying this framework is to sample analog signals at sub-Nyquist rate and to classify directly compressed measurement into normal and abnormal state. Minimizing the wire connected electrodes to the platform can make the carrier more comfortable because two electrodes are attached closely on the surface of the body. Recording difference ECG is analyzed using Vectorcardiogram (VCG) theory. Experimental results show that an integrated, low cost, and user-friendly SoC-Holter is feasible. SoC-Holter consumes less than 10mW while the device is operating. It takes advantage of estimating parameters directly from compressed measurements, thereby eliminating the reconstruction stage and reducing the computational complexity on the platform. In addition, the framework provides compressed ECG signals without loss of information, reducing significantly the power consumption for message sending and memory storage space. The effect of electrode placement is evaluated by estimating QRS complex in recorded ECG signals by two adjacent electrodes. The method is based on the QRS-VCG loop alignment algorithm that estimates Least Square (LS) between an observed VCG loop and a reference loop with respect to the transformations of rotation and time synchronization. The electrode location with less sensitive to interference is investigated.