James J. Bailey

Improved detection of echocardiographic left ventricular hypertrophy using a new electrocardiographic algorithm

OBJECTIVESnThe purpose of this study was to use the Framingham data base to devise and test an improvement in an electrocardiographic (ECG) voltage criterion for detecting left ventricular hypertrophy that is gender specific and adjusts for age and obesity.nnnBACKGROUNDnElectrocardiographic detection of left ventricular hypertrophy has been receiving increasing attention. The Cornell ECG voltage, defined as the sum of voltages for the R wave of lead aVL and S wave of lead V3, has been shown to correlate strongly with echocardiographically estimated left ventricular mass. Because the magnitude of this voltage varies with both age and obesity, we have proposed a simple formula for its adjustment for these two variables.nnnMETHODSnUsing linear regression, the adjustment formula was estimated from data on 1,468 men and 1,883 women from the Framingham Heart Study cohort who were free of myocardial infarction and who had both an ECG and an echocardiogram recorded during the same clinic examination. A modified receiver operating characteristic curve method was used to compare sensitivities at the same specificity levels. The adjustment formula was estimated from one randomly chosen half of the study cohort and applied to the other half for evaluation.nnnRESULTSnSignificant improvement in sensitivity for the detection of left ventricular hypertrophy was realized at all levels of specificity. At a specificity level of 98%, the adjustment increased the sensitivity of the Cornell voltage from 10% to 17% in men and from 12% to 22% in women. For severe hypertrophy, defined as a left ventricular mass > 3 SD above the gender-specific mean, the sensitivity increased from 23% to 38% for men and from 22% to 55% for women at a specificity level of 95%.nnnCONCLUSIONSnThis approach can substantially enhance the utility of the ECG for the detection of left ventricular hypertrophy. If these results are validated in other population groups, this approach may prove valuable in the screening of hypertensive populations and for the monitoring of patients undergoing treatment for hypertension.

A Method for Evaluating Computer Programs for Electrocardiographic Interpretation II. Application to Version D of the PHS Program and the Mayo Clinic Program of 1968

A previously described method for evaluating computer programs for electrocardiographic (ECG) interpretation was applied to Version D of the Public Health Service (PHS) program and to the Mayo Clinic program of 1968. Staff cardiologists found agreement with the results of the PHS program in 45.5% of 1150 unselected tracings. Clinically significant disagreements based strictly on application of different criteria occurred in 29%, while disagreements based on program errors were found in 25.5%. The corresponding results for the Mayo Clinic program are: agreement in 47%, disagreements due to criteria differences in 30.9%, and disagreements due to program errors in 22.1%.Both programs had serious deficiencies, particularly in the diagnostic categories of myocardial infarction and cardiac arrhythmias. PHS program errors resulted primarily from mismeasurements and deficient program logic, while Mayo Clinic program errors more frequently resulted from pattern recognition failures. Neither program appears suitable for routine clinical use at the present time.

A Method for Evaluating Computer Programs for Electrocardiographic Interpretation I. Application to the Experimental IBM Program of 1971

A method for evaluating computer programs for electrocardiographic interpretation is described. This method allows a clinician to judge the usefulness of a program for his specific setting and needs. The method requires a significant proportion and variety of abnormal tracings, the application of specific fixed criteria, and the separation of disagreements between the computer program and the clinician into those resulting from criteria differences and those resulting from programming errors, viz., pattern recognition failures, mismeasurements, and/or deficient program logic. When applied to the experimental IBM program 1971, staff cardiologists found essential agreement with the programs results in 76% of 1150 unselected tracings. Clinically significant disagreements based strictly on the application of different criteria occurred in 20% of the tracings, whereas disagreements based on program errors were found in only 4%. Although this program requires some system of human overview and quality checking, its potential for clinical implementation is worthy of consideration.

A Method for Evaluating Computer Programs for Electrocardiographic Interpretation III. Reproducibility Testing and the Sources of Program Errors

A simple method for testing reproducibility in ECG computer program performance results from using two digital representations of the same analog ECG tracing. Each digital representation is separated from the other by one millisecond in time. When the digital representations are processed by the Mayo Clinic program (1968), the diagnostic statements are identically reproduced in only 60% of 33 tracings. When the method is applied to version D of the PHS program and to the newly released IBM program of 1973, identical reproducibility is 43.3% and 76.0%, respectively, of 217 tracings. After analog filtering these figures are improved to 49.8% and 79.7%, respectively. These results show that reproducibility is most affected by a programs algorithms for pattern recognition, measurement, consistency checking, and noise handling. Reproducibility is less affected by attenuation of high frequency noise at the analog level. The relationship of reproducibility to program error rate in previous studies is discussed. Hence poor performance on this test obviates the need for a more time-consuming clinical evaluation. The need for human overview and quality checking is re-emphasized.

The Measurement of Left Ventricular Function and the Detection of Wall Motion Abnormalities with High Temporal Resolution Ecg-Gated Scintigraphic Angiocardiography

An ECG-gated, scintigraphic imaging procedure is described in which a complete, average cardiac cycle is visualized with high temporal resolution. The ability of this method to detect wall motion abnormalities and quantitate left ventricular function is illustrated in a patient with severe coronary artery disease. These results are compared to (contrast) angiographic findings in the same patient.

A filter to suppress ECG baseline wander and preserve ST-segment accuracy in a real-time environment

Accurate monitoring of the ST-segment displacements in real-time environments can be distorted by the nonlinear phase response of a baseline filter such as the single-pole, high-pass (0.5 Hz) filter that is standard in the industry today. The authors have previously constructed a four-pole null phase (1.0 Hz) filter that is nearly ideal in suppressing baseline wander while preserving ST-segment accuracy; however, this foreward/backward filter requires capture of a large ECG segment before filtering, thereby producing a delay that is unacceptable in a real-time environment. As a practical compromise, a two-pole, phase-compensated (1.0 Hz) filter was constructed while introducing a small time delay (160 ms). It performs much better than the standard filter and almost as well as the ideal filter in several tests, namely (1) suppression of baseline wander in a series of ECGs, (2) suppression of artificial baseline, (3) response to a triangular impulse wave (American Heart Association test), and (4) J-point displacement in several ECGs.

NHLBI workshop on the utilization of ECG databases: Preservation and use of existing ECG databases and development of future resources

Baseline examinations and periodic reexaminations in longitudinal population studies, together with ongoing surveillance for morbidity and mortality, provide unique opportunities for seeking ways to enhance the value of the electrocardiogram (ECG) recorded with digital technology as an inexpensive and noninvasive tool for prognosis and diagnosis. Clinicians, epidemiologists, and engineers from industry, government, and academic medical centers gathered at a workshop sponsored by the National Heart, Lung, and Blood Institute (NHLBI) on June 11-12, 1997, to discuss the research potential of ECG databases, their preservation and accession, and standards for recording and storage. Databases considered were those acquired in ongoing and future NHLBI-funded studies and in clinical settings in which the ECG continues to provide valuable information for evaluation and treatment. The accessibility of existing databases, the quality of their data, and the availability of ancillary demographic and clinical information were major themes. Also discussed were appropriate statistical methodologies to be used with these data for developing and testing ECG algorithms. The workshop participants affirmed the value of these databases and urged the establishment of an ECG advisory and review group to (1) resolve technical and proprietary issues for the utilization of currently existing databases; (2) develop standards for recording, storage, and utilization of ECGs in future NHLBI-supported studies; (3) oversee the creation of a national ECG database resource, consisting of an archive of ECG databases from past and ongoing NHLBI-supported studies, and a registry of ECG databases that would eventually include digital ECGs from populations currently underrepresented in the demographic spectrum of the NHLBI databases.

The importance of reproducibility testing of computer programs for electrocardiographic interpretation: application to the automatic vectorcardiographic analysis program (AVA 3.4).

Abstract The automatic vectorcardiogram analysis (AVA 3.4) program developed by Pipberger and associates has a unique manner of using multivariate statistics to make morphological diagnoses of the QRS and P waveforms. This scheme produces statements of probabilities for up to seven different QRS diagnoses and three different P wave diagnoses. It would require a complicated protocol with a very large population to establish the validity of this approach. However we have described a simple method for evaluating that part of an ECG program which is independent of its criteria or clinical accuracy. Poor performance on this test obviates the need for more time-consuming clinical evaluation. Results of applying this test to the AVA 3.4 program are reported.

A computer processing system for ECG-gated radioisotope angiography of the human heart

Abstract Various methods of radioisotope angiography have shown considerable promise as a noninvasive tool for cardiac diagnosis. Some of these methods use ECG gating and several cardiac cycles to build up scintigraphic images at end-systole and end-diastole. None of these methods result in data points between end-systole and end-diastole which could be used to construct ventricular volume curves or cineangiograms of a complete cycle. The purpose of this paper is to describe a computer processing system which extracts a set of 80–100 scintigraphic images from 1200–1500 heartbeats. This set of images representing a complete, typical cardiac cycle can be displayed as a cineangiogram or can be further analyzed and processed to yield various parameters of ventricular performance, such as ejection fraction, fractional ejection rate (mean and peak values), rate of circumferential fiber shortening (mean and peak), ejection duration, and time to peak flow.

A kinetic model of CD4+ lymphocytes with the human immunodeficiency virus (HIV)☆

This report describes a kinetic model of in vitro cytopathology involving interactions of human immunodeficiency virus (HIV) with CD4+ helper T lymphocytes. The model uses nonlinearly coupled, ordinary differential equations to simulate the dynamics of infected and uninfected cells and free virions. It is assumed that resting cells are more readily infected than activated cells, but once infected, only activated cells produce more virus. Resting cells can be activated by some appropriate stimulus (e.g. phytohemagglutinin, soluble antigen). The model predicts that the initial inoculum of virus is taken up by resting cells and without stimulation the system comes to a steady state of two populations, namely infected and uninfected cells. Stimulation of this system produces two additional populations, namely infected and uninfected activated cells which, along with the previous populations, exhibit cyclic behavior of growth, viral expression/release, and death. Additional stimuli enhance or diminish the cyclic behavior depending upon their occurrence in time. These simulations suggest a similar dynamics in human HIV infection and may explain a major factor responsible for the widely varying depletion rate of (CD4+) helper T cells in AIDS patients.