An Electronic Stethoscope with Diagnosis Capability

Wah W. Myint
Department of Comp. Science and Software Eng. Auburn University, College of Engineering Auburn, AL 36849 USA
Abstract A means of analyzing acoustic heart sounds is described. The system analyzes heart sound data, isolating key features of the heartbeat signatures to produce a list of possible diagnoses. The system has six major components: heart beat extraction, segmentation of the heart sound cycle, extraction of murmur data, time-frequency analysis of murmurs, statistical metrics and diagnoses algorithms. Implementation of each component is discussed in detail. Diagnoses algorithms for the following events/conditions are included: heart rate, sinus arrhythmia, tachycardia, bradycardia, aortic stenosis and mitral regurgitation.

Bill Dillard
Department of Electrical & Computer Eng. Auburn University, College of Engineering Auburn, AL 36849 USA blood can move through the smaller opening. If a valve does not close tightly, blood may leak backward, or regurgitate. In auscultation, these conditions are called murmurs and can occur in either systole or diastole, as seen in Fig. 1b. Stenosis occurs when a valve does not open completely. The valve may have become hardened or stiff with calcium deposits or scarring, so it is hard to push open. Blood has to flow through a smaller opening, so less blood gets through the valve into the next chamber. Insufficiency (also called regurgitation) results when the valve does not close tightly. The valve's supportive structures may be loose or torn. Or the valve itself may have stretched or thinned. Blood then may leak back in the wrong direction through the valve.
S1 Sys tole S2 Dias tole S1 Sy stole S2

I. INTRODUCTION It has been reported that a disturbing percentage of medical school graduates cannot properly use a stethoscope for diagnosing common heart conditions [1]. This is true despite the availability of computerized training modules that provide acoustic and visual display of heart sounds [2,3]. Furthermore, many physicians rely heavily on ECG and EKG specialists, leading to higher health care costs and a general decline in stethoscope skills. In this work, we consider analyzing heart sounds using time-frequency techniques, beginning with auscultation and moving towards diagnosis. Results will be applied to an electronic diagnostic stethoscope (EDS) suitable for medical school training. II. HEART SOUNDS AND MURMURS The heart is divided into four chambers. The upper chambers are called atria and the lower chambers are called ventricles. The heart muscle squeezes blood from chamber to chamber. At each squeeze, the valves open to let blood through to the next chamber. Then the valves close to stop blood from moving backward. In this way, the valves keep blood moving as efficiently as possible through the heart and out to the body. Under normal heart conditions, there are basically two heart sounds, S1 and S2, shown in Fig. 1a. S1 sound corresponds to the near simultaneous closure of the mitral and tricuspid valves after blood has returned from the body and lungs. This is the start of systole. The S2 sound, signaling the end of systole and the beginning of diastole, is created by the closing of the aortic and pulmonic valves as blood exits the heart to the body and lungs. Valvular disease occurs when a valve does not work the way it should. If a valve does not open all the way, less

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Sys tolic Murmur Dias tolic Murmur

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Fig. 1. Representative heart sounds for (a) a normal heart and (b) a heart with both systolic and diastolic murmurs.

III. THE ALOGRITHMS A. Heart Rate Issues The system is capable of extracting heart rate as well as diagnosing abnormal heart rate conditions: sinus arrhythmia, bradycardra and tachycardia. Acoustic heart sound data is acquired by a microcomputer sound card and stored as a wave table file. The algorithm for extracting the heart rate is diagrammed in Fig. 2a and begins with the normalization of the data file such that the maximum value
nmax = 0 max = 0

is unity. Next, the envelope is detected and compared against a pre-selected hysteresis window, as shown in Fig. 2b. Upon crossing the positive threshold, the sample index number at the envelope maximum is found. When the envelope falls below the negative threshold, the index is stored. This technique rejects noise in the envelope. This is repeated for three envelope peaks, providing either a S1S2-S1 or a S2-S1-S2 timing sequence. In either case the first and last stored times provide the heart rate through the equation 60 f S (1) n where fs is the sampling frequency, n = n3 n1 is the number of samples in the heart beat cycle and HR is the heart rate in beats per minute. Three heart rate conditions are combined into the single algorithm diagrammed in Fig. 3. The first condition, sinus arrhythmia, is characterized by a heart rate within normal limits but irregular [4]. It is detected by comparing the duration of adjacent heart beats. If the ratio (n3-n2)/(n2-n1) falls where a pre-determined window, then the heart beat pair is regular and the Normal Beat Counter (NBC) is incremented. Otherwise, the Sinus Arrhythmia Counter (SAC) is incremented. The ratio of the counters provides an indication of sinus arrhythmia. HR =

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data > pos. threshold? yes data > max? no data < neg. threshold? yes DONE (a)
1.25 normaliz ed magnitude 1 0.75 0.5 0.25 0 0 0.5 n1 n2

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(b) Fig. 2. Extracting the heart rate relies on finding the index number, nmax, of the envelope peaks. The flowchart (a) describes how a single peak index number is determined. Hysteresis (b) is employed to reject noise in the envelope data.

DONE Fig.3. A flowchart describing how a series of counters are used to detect heart beat related conditions.

The phenomenon of bradycardia is characterized by a heart rate below 60 beats per minute and a regular rhythm [5]. It is easily detected by monitoring the heart rate. If a heart beat duration is too long, the Bradycardia Counter (BC) is incremented. The nearness of the ratio BC/NBC to unity indicates the severity of the bradycardia. At the opposite end of the heart rate spectrum, in tachycardia, the heart rate exceeds 150 beats per minute [5]. In a manner similar to the bradycardia algorithm, the Tachycardia Counter (TC), in conjunction with the NBC, is used to diagnose this condition. B. Segmentation of the Heart Cycle Before murmur analysis can begin, the systolic and diastolic phases must be delineated. This process is called segmentation. True segmentation based solely on acoustic data is a difficult procedure [6,7]. In fact, many researchers use ECG recordings to identify the S1 sound [8,9]. In this work, a simple approach is used based on the peak index numbers, n1, n2 and n3 defined in Fig. 2a. Generally, the systolic phase is shorter than the diastolic. This leads to the segmentation scheme described in (2). If If n3 n 2 > 1 then n1 is S1 n 2 n1 n3 n 2 < 1 then n1 is S 2 n 2 n1

(2)

fully, leading to abnormally high pressure in the left ventricle. The time-frequency signature for AS, shown in Fig. 4a, exhibits a crescendo-decrescendo in magnitude at relatively uniform frequency across the systolic phase. In mitral regurgitation (MR), the mitral valve does not completely close during systole, allowing blood to flow backwards into the left atrium. As shown in Fig. 4b, MR exhibits relatively uniform magnitude and frequency during systole. Unfortunately, it is common for murmur characteristics to vary between heart cycles. Additionally, the S1 and S2 sounds often dominate the murmurs. It is vital, therefore, that a time-frequency analysis be performed on each systolic and diastolic murmur with S1 and S2 sounds rejected [11]. To this end, a separate data file will be created for each murmur event. Referring to Fig. 2a, when the envelope falls below the negative threshold, a new file can be opened and data written until crossing the positive threshold, where the file is closed. This will isolate the murmur from S1 and S2. The segmentation results form (2) identify the murmur phase systolic or diastolic. In this way, murmur files are created sequentially, alternating between systole and diastole. The time-frequency analysis is performed using the specgram function in MATLAB, which produces a local spectrum versus time. A representative spectrograph for an AS murmur is shown in Fig. 5, where magnitude is displayed in grayscale. The characteristic crescendodecrescendo pattern is readily apparent. A spectrograph is
S1 s ys tole S2

As heart rate increases, the duration of the diastolic phase decreases while the systolic phase is relatively fixed. At very high heart rates the inequalities in (2) may reverse. This is the weakness of such a simple segmentation scheme and the impetus for using ECG in segmenting. C. Time-Frequency Analysis Of Murmur Sounds At the beginning of systole, the mitral and tricuspid valves close, causing the S1 sound. The ventricles squeeze, forcing blood through the aortic and pulmonary valves into the atria and on to the body and lungs. When ventricular pressure drops, the arotic and pulmonary valves close, causing S2, signaling the end of systole and the beginning of diastole. During diastole, blood reenters the atria. The increased pressure opens the mitral and tricuspid valves, allowing the ventricles to refill. Valves that do not open fully cause reduced flow, whereas, those that do not close properly, allow blood to flow backwards. In either case, the faulty valve causes turbulence, producing murmurs. Some murmurs have characteristic time-frequency signatures that can be used for identification and diagnoses [10]. In this work, two specific systolic murmurs are selected for analysis, aortic stenosis and mitral regurgitation. In aortic stenosis (AS), the aortic valve is thickened and narrowed. As a result, it does not open

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(b) Fig. 4. Representative waveforms for (a) aortic stenosis and (b) mitral regurgitation demonstrate their time-frequency characteristics.

Perform spectrogram

Calculate statistics: (peak magnitude, frequency at peak, average magnitude, standard deviation of magnitude) for each localized spectrum. Calculate the averages and standard deviations of the peak magnitudes and their frequencies across the murmur duration

Small standard deviations and reasonable average values indicate MR Fig. 6. A procedure of analyzing spectrogram data for the occurrence of mitral regugitation within a single murmur. Fig. 5. A spectrogram for a representative aortic stenosis murmur indicating the crescendo-decrescendo, uniform frequency nature of the data.
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produced for each murmur data file and statistical characteristics, such as peak magnitude, frequency at peak magnitude, average and standard deviation are calculated for each local spectrum. These statistics are used to produce diagnoses of AS and MR. D. Murmur Diagnoses As seen in Fig. 4b, mitral regurgitation is characterized by the uniform frequency and magnitude during the systolic phase. The severity of MR is indicated by the magnitude relative to S1 and S2. Thus, a reasonable procedure for diagnosing MR is diagrammed in Fig.6. From the spectrograph data, the averages and standard deviations of the peak spectral component and its corresponding frequency are calculated for the duration of the murmur. If the standard deviations are small, and the average frequency is reasonable, then MR is diagnosed, with the average of the peak frequency component indicating severity. The same procedure can be used for characterizing the frequency of the aortic stenosis murmur sounds. However, referring to Fig. 4a., it is obvious that a different approach is required to identify the crescendo-decrescendo nature of the magnitude. As shown in Fig. 7, the time at which the maximum magnitude occurs is first extracted. Separate least square fits are performed on the magnitude-time data on both sides of the peak and the resulting slopes and correlation parameters are stored. Based on the slopes, correlation parameters and peak magnitude, numerical values can be assigned to the possibility and severity of AS. After each murmur event has been analyzed, the results are tabulated and evaluated for consistency across

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Figure 7. A simple procedure for diagnosing AS relies on its crescendodecrescendo nature at relatively uniform frequency.

the entire auscultation period, yielding a final diagnosis of heart conditions. IV. RESULTS To test the algorithm, a wave table file of acoustic data obtained from a patient with mitral regurgitation was segmented and a single murmur isolated for analysis. From the spectrogram of the murmur is shown in Fig. 8, where the murmur duration is divided into 10 time segments. In each time segment, the peak spectral content and its frequency are extracted. Mean and standard deviation are then calculated across the murmur duration. Results, listed in Table I, show peak magnitude and frequency values, consistent with the mitral regurgitation condition. Time segments 1 and 10 contain S1-S2 artifacts and have been omitted in the analysis. Algorithms for aortic stenosis were also conducted on an isolated AS murmur. The murmur envelope was normalized and least square fits were obtained on both sides of the maximum peak. Results are shown in Figure 9 and Table II. Correlation parameters of 0.857 and 0.829,

in conjunction with the slope magnitudes, are compatible with aortic stenosis.

V. CONCLUSIONS The initial work towards an electronic diagnostic stethoscope has been reported. Methods for analyzing acoustic heart sound data have been presented, including algorithms for extracting heart rate and diagnosing raterelated abnormalities. Additional algorithms for murmur analysis, specifically mitral regurgitation and aortic stenosis have been demonstrated. Future tasks include data acquisition hardware design, software integration and graphic user interface (GUI) development. VI. ACKNOWLEDGEMENTS The authors gratefully acknowledge Dr. Jennifer Chu of University of Pennsylvania Medical Center, Mr. Zaw Maung of Nortel Networks and Dr. Gerry Dozier of Auburn University for their medical and technical contributions to this work. VII. REFERENCES S. Mangione, L. Nieman, Cardiac aucsultatory skills of internal medicine and family practice trainees, Journal of the American Medical Association, vol. 278, pp 717 722, 1997. [2] RALE: Lung and Heart Sound CAI Software, Published by PixSoft. Inc. [3] CardioSim Digital Heart Sound Simulator, Published by Cardionics, Inc. [4] J. Constant, Bedside Cardiology, Boston, MA: 1993, pp. 143. [5] L.M. Porterfield, ECG Fundamentals, Springhouse Corporation, Springhouse, PA: 1997, pp 65. [6] H. Liang, S. Lukkarinen, I. Hartimo, Heart sound sementation algorithm based on heart sound envelogram, in Computers in Cardiology, 1997, pp. 105-108. [7] H. Liang, S. Lukkarinen, I. Hartimo, A boundary modification method for heart sound segmentation algorithm, in Computers in Cardiology, 1998, pp. 593-595. [8] B. Altrabsheh, J.N. Torry, Detecting the split within heart sounds using a switched-capacitor filter, in Computers in Cardiology, 1998, pp. 597-600. [9] M.W. Groch, J.R. Domnanovich and W.D. Erwin, A new heart-sounds gating device for medical imaging, IEEE Trans. on Biomedical Engineering, vol. 39, 1992, pp. 307 310. [10] B. Tovar-Corona, J.N. Torry, Graphical representation of heart sounds and murmurs, in Computers in Cardiology, 1997, pp. 101 104. [11] A. Haghighi-Mood, J.N. Torry, Time-frequency analysis of systolic murmurs, in Computers in Cardiology, 1997, pp. 113 116. [1]

Fig. 8. Spectrograph of a murmur from a patient with mitral regurgitation.

TABLE I STATISTICS FOR THE MITRAL REGURGITATION SPECTROGRAPH IN FIG. 8

Stat Max. Freq. Time Segment 2 3 4 5 6 7 8 0.46 0.49 0.42 0.81 0.60 0.71 0.68 215 118 129 11 215 97 129 Full Murmur 9 Mean STD 0.72 0.61 0.14 86 125 67

Fig. 9. The algorithm for detecting aortic stenosis performs least squares fits to the normalized murmur envelope before and after peak magnitude

TABLE II LEAST SQUARES FIT FOR THE AORTIC STENOSIS MURMUR IN FIG. 9 Slope Intercept Correlation (r) Before 10.549 0.519 0.857 After -4.371 0.913 -0.829