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A methodology for the automated creation of


Arti?cial Intelligence in Medicine (2007) 40, 187—200

http://www.intl.elsevierhealth.com/journals/aiim

A methodology for the automated creation of fuzzy expert systems for ischaemic and arrhythmic beat classi?cation based on a set of rules obtained by a decision tree
Themis P. Exarchos a,b, Markos G. Tsipouras a, Costas P. Exarchos a, Costas Papaloukas a,c, Dimitrios I. Fotiadis a,d,e,*, Lampros K. Michalis e,f
Unit of Medical Technology and Intelligent Information Systems, Department of Computer Science, University of Ioannina, GR 45110 Ioannina, Greece b Department of Medical Physics, Medical School, University of Ioannina, GR 45110 Ioannina, Greece c Department of Biological Applications and Technology, University of Ioannina, GR 45110 Ioannina, Greece d Biomedical Research Institute-FORTH, GR 45110 Ioannina, Greece e Michaelideion Cardiology Centre, GR 45110 Ioannina, Greece f Department of Cardiology, Medical School, University of Ioannina, GR 45110 Ioannina, Greece
Received 6 October 2006; received in revised form 19 February 2007; accepted 5 April 2007
a

KEYWORDS
Fuzzy expert system; Data mining; Optimization; Ischaemia; Arrhythmia

Summary Objective: In the current work we propose a methodology for the automated creation of fuzzy expert systems, applied in ischaemic and arrhythmic beat classi?cation. Methods: The proposed methodology automatically creates a fuzzy expert system from an initial training dataset. The approach consists of three stages: (a) extraction of a crisp set of rules from a decision tree induced from the training dataset, (b) transformation of the crisp set of rules into a fuzzy model and (c) optimization of the fuzzy model’s parameters using global optimization. Material: The above methodology is employed in order to create fuzzy expert systems for ischaemic and arrhythmic beat classi?cation in ECG recordings. The fuzzy expert system for ischaemic beat detection is evaluated in a cardiac beat dataset that was constructed using recordings from the European Society of Cardiology ST-T database. The arrhythmic beat classi?cation fuzzy expert system is evaluated using the MIT-BIH arrhythmia database.

* Corresponding author at: Unit of Medical Technology and Intelligent Information Systems, Department of Computer Science, University of Ioannina, PO Box 1186, GR 45110 Ioannina, Greece. Tel.: +30 26510 98803; fax: +30 26510 98889. E-mail address: fotiadis@cs.uoi.gr (D.I. Fotiadis). 0933-3657/$ — see front matter # 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.artmed.2007.04.001

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Results: The fuzzy expert system for ischaemic beat classi?cation reported 91% sensitivity and 92% speci?city. The arrhythmic beat classi?cation fuzzy expert system reported 96% average sensitivity and 99% average speci?city for all categories. Conclusion: The proposed methodology provides high accuracy and the ability to interpret the decisions made. The fuzzy expert systems for ischaemic and arrhythmic beat classi?cation compare well with previously reported results, indicating that they could be part of an overall clinical system for ECG analysis and diagnosis. # 2007 Elsevier B.V. All rights reserved.

1. Introduction
Cardiovascular diseases are the leading cause of death in many countries worldwide. The multifaceted nature of the diseases, combined with a wide variety of treatments and outcomes and complex relationships with other diseases, have made diagnosis of cardiovascular diseases a highly complex and important task, even for experienced cardiologists. Two of the most common cardiovascular diseases are myocardial ischaemia and cardiac arrhythmias. Myocardial ischaemia is the most common cardiac disorder and its early diagnosis is of great importance. It is de?ned by a reduced blood ?ow to parts of the myocardium which causes alterations in the ECG signal, such as deviations in the ST segment and changes in the Twave [1]. Several techniques, which automate the detection and assist in the diagnosis of ischaemia in long duration ECGs have been proposed [2—16]. All these techniques can be described as a sequence of two tasks: ischaemic beat detection and ischaemic episode de?nition. The ?rst is related to the classi?cation of beats as normal or ischaemic, which is a key process for the de?nition of the ischaemic episodes in the ECG signal. Several techniques have been proposed for ischaemic beat detection which evaluate the ST segment changes and the T-wave alterations by different methodologies. More speci?cally, the use of approaches like statistical signal processing [2—4], fuzzy theory [5], wavelet theory [6], set of rules [7,8], arti?cial neural networks [9—13], multicriteria decision analysis [14], genetic algorithms [15] and association rule mining [16] have been previously reported. Signal processing [2—6] and neural networks [9—13] based approaches have resulted in high performance but require further post processing of the input parameters along with their weights in order to provide useful information. Rule-based approaches exhibit the highly desirable feature of interpreting the decisions but their performance is lower. In what concerns cardiac arrhythmia, it can be de?ned as either an irregular single heartbeat (arrhythmic beat), or as an irregular group of heartbeats (arrhythmic episode). Arrhythmias can affect

the heart rate causing irregular rhythms, such as slow or fast heartbeat. Arrhythmias can take place in a healthy heart and be of minimal consequence, but they may also indicate serious cardiovascular problems, which may lead to stroke or sudden cardiac death [17]. The ECG beat-by-beat analysis and classi?cation can provide important information regarding the subject’s cardiac condition. Several methods have been proposed in the literature for arrhythmic beat classi?cation, where each beat is classi?ed into several different rhythm types utilizing ‘‘mixture of experts approach’’ [18], hermite functions combined with self-organizing maps [19], arti?cial neural networks [20,21], fuzzy neural networks [22], autoregressive modelling [23], timefrequency analysis combined with knowledge-based systems [24], support vector machines [25], ECG morphology [26] and rule-based systems [27]. Expert systems are a branch of arti?cial intelligence that makes extensive use of specialized knowledge to solve problems at the level of a human expert. This knowledge is represented by a set of rules [28]. An area where expert systems are widely employed is the medical domain. Several parameters must be taken into consideration in order to create a medical expert system; the representation of medical knowledge and expertise, the decision making, and the choice and adaptation of a suitable model, are some of them. Also, uncertainty and imprecision, inherited in medical problems, is treated incorporating fuzzy logic [29,30]. Fuzzy expert systems (FES) include a set of fuzzy rules comprising a fuzzy model, while some of the model’s parameters can be adjusted using global (or local) optimization techniques. In this context, several approaches have been proposed in the literature: optimization of fuzzy rules with genetic algorithms [15,31] or simulated annealing [32]. Neuro-fuzzy algorithms have also been proposed [33]. In the latter, the fuzzy rules are modelled using an arti?cial neural network (ANN) and training techniques are employed. Also, a great effort has been made in the induction of decision trees using fuzzy partitions (fuzzy decision trees) and optimization of the parameters entering these trees [34—39]. Most of the works in this ?eld

Methodology for the automated creation of fuzzy expert systems employ genetic algorithms for the optimization of the fuzzy partitions [37—39]. In all the above research attempts, it has been shown that fuzzy decision trees and fuzzy rules, after the optimization of the parameters used, increase the accuracy of the respective crisp models signi?cantly. In this study, a methodology for the automated creation of fuzzy expert systems (FES) is proposed, that involves three stages: (i) extraction of a set of rules using data mining, (ii) generation of a fuzzy model, and (iii) optimization of the fuzzy model’s parameters. Speci?cally, a set of rules is extracted from a decision tree, developed from a training set. In the second stage, the set of crisp rules is fuzzi?ed, resulting into a fuzzy model. Finally, all the parameters entering the fuzzy model are tuned with respect to the classi?cation accuracy of the fuzzy model, using global optimization. The fuzzy model with the optimized parameters composes the ?nal FES. The generated FESs are able to provide interpretation for their decisions since they are based on sets of rules. In the ?rst stage of the methodology, the use of data mining in the form of decision trees has the advantage of discovering new knowledge [40,41]. More speci?cally, the initial set of rules is extracted from a decision tree, which is considered a very effective technique for classi?cation [37,42,43]. Furthermore, the development of the fuzzy model from the initial set of rules and the optimization of its parameters, improve the results obtained by the decision tree, while the incorporation of fuzzy logic addresses the uncertainty inherent in several classi?cation problems [29]. We have employed the above methodology in two medical problems: ischaemic and arrhythmic beat classi?cation. Those problems are considered very important in the context of clinical cardiology. In both cases, representative features are extracted from the cardiac beats. The QT interval, along with features extracted from the ST—T interval were used for ischaemic beat detection while features from the tachogram were employed for arrhythmic beat classi?cation. In what concerns ischaemia, the QT interval and more speci?cally the corrected QT (QTc) interval has great clinical signi?cance and is widely used in clinical practice since it is affected by various clinical conditions such as myocardial ischaemia or infarction with deep T wave inversion [44,45]. Also, the ST—T characteristics are known for their ischaemic diagnostic ability [46,47], while the tachogram can be used to characterize several types of cardiac arrhythmias [27,48]. In the case of ischaemia the classi?cation output for each beat is normal (Norm) or ischaemic (Isch), while in the case of arrhythmia four classes are considered: beats belonging to ventricular ?utter/?brillation episodes

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(VF), premature ventricular contractions (PVC), normal beats (N) and beats belonging to 28 heart block episodes. The classi?cation is performed using data from two task speci?c cardiac beat databases and the obtained results indicate that the proposed methodology is very effective and performs well both in terms of sensitivity and speci?city. In the following, we describe the proposed methodology in detail, the employed datasets, the preprocessing of the electrocardiographic (ECG) signal and the features used to create the FESs, for the two medical applications. Next the results of the evaluation are presented. The advantages and the disadvantages of the proposed methodology are given in Section 5. Comparison with previous works, as well as, possible further improvements are also discussed.

2. Materials and methods
The methodology automatically generates a FES, using an initial annotated dataset. The methodology involves three stages: (i) creation of a rule-based classi?er using the annotated dataset, (ii) development of a fuzzy model, and (iii) optimization of the fuzzy model’s parameters. The ?owchart of the methodology is shown in Fig. 1; all stages are described below in detail. Brie?y, an initial set of (crisp) rules is extracted from a decision tree, induced by the annotated dataset. The set of rules is transformed to a fuzzy model using a fuzzy membership function and fuzzy equivalents of the binary AND and OR operators. Finally, the fuzzy model is optimized with respect to its parameters, using the annotated dataset.

2.1. Extraction of a set of rules
In order to extract an initial set of rules from an annotated dataset, a rule mining technique must be employed. In our approach we used decision trees, however any rule mining technique could be employed. The construction of the decision tree is implemented using the C4.5 inductive algorithm [42], which is an effective and widely used decision tree induction algorithm and requires low computational effort [37,43]. C4.5 generates a decision tree from the training data that minimizes the expected value of the number of tests for data classi?cation. Each internal node of the tree corresponds to a feature (aj), while each outgoing branch corresponds to a feature test (ajopuj), where (ajuj) is a feature—threshold pair and op is a comparison operator chosen from the set {=, 6?, <, >, , !}. Each feature test j forms a (crisp) conjunct cj(aj, uj),

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T.P. Exarchos et al. error. The con?dence factor for pruning was set to 0.25. The produced tree can be easily transformed into a set of rules, as follows: (a) One condition (Condi) is created for every leaf of the tree, by parsing the tree from the root node to that leaf. The feature tests encountered along the path form the conjuncts of the condition: Condi ?A; Q? ? croot ?aroot ; uroot ? ^ cn j ?an j ; un j ? ^ ? ? ? ^ cnk ?ank ; unk ?; (2) where Condi is a condition, A ? fa1 ; a2 ; . . . ; anf g is the feature vector, Q ? fu1 ; u2 ; . . . ; unt g is a vector containing all thresholds, nf is the number of features characterizing a record, nt is the total number of thresholds used in the decision tree. The class label at the leaf node is assigned to the rule consequent: Condi(A, Q) ! y, where y is the class. (b) A general rule (Ry) is created for each class, using all the conditions Condi(A, Q) having as consequent this class: Ry ?A; Q? ? Cond j1 ?A; Q? _ Cond j2 ?A; Q? _ ? ? ? _ Cond jn ?A; Q?; (3) where y is the class. These general rules comprise the crisp set of rules, which are in a disjunctive normal form.

Figure 1 The proposed three-stage methodology for the automated generation of a fuzzy expert system (FES).

which, if op 2 { , >} it is expressed as: cj(aj, uj) = gc(aj, uj), where gc is the crisp membership function, de?ned as ( 0 a u inc ?increasing? or gc ?a; u? ? 1 a>u ( 1 a u dec ?decreasing?: (1) gc ? a ; u ? ? 0 a>u The leaf nodes represent the class to be assigned to a sample. The most important factor in the C4.5 algorithm is its ability to automatically select the feature, which is appropriate at each node. The feature of each node is selected in order to divide input samples effectively. Information gain [42] is used as a measure of effectiveness. After the induction of the decision tree, we apply a pruning method to reduce the tree’s size and complexity. There exist two common methods for pruning [42]: prepruning and post-pruning. In our problem we followed the post-pruning method. Post-pruning tends to give better results than prepruning since it makes pruning decisions based on a fully grown tree, unlike prepruning, which can suffer from early termination of the tree growing process. In our case, post-pruning is performed by replacing a subtree with a new leaf node whose class label is determined from the majority class of records associated with the subtree (subtree replacement). The subtree replacement was performed by calculating the pessimistic

2.2. Development of a fuzzy model
A fuzzy model is based on three fundamental aspects: the fuzzi?cation method, the inference engine and the deffuzi?cation [49]. Different combinations of the realizations of the above aspects result to different fuzzy models. In our approach, the crisp set of rules is transformed into a fuzzy model using a fuzzy membership function instead of the crisp one. The sigmoid function, de?ned as 1 ginc ?increasing? or s ?a; u 1 ; u2 ? ? 1 ? eu1 ?u2 ?a? 1 ?decreasing?; (4) gdec s ?a; u 1 ; u2 ? ? 1 ? e u 1 ? a? u 2 ? is used as fuzzy membership function, for the fuzzi?cation of the inputs. According to this, the crisp conjuncts are transformed to fuzzy ones as: cfj ?a j ; u1; j ; u2; j ? ? gs ?a j ; u1; j ; u2; j ?. The fuzzy inference engine is de?ned establishing the Tand S norms de?nitions (among the several de?nitions and classes that have been proposed in the literature) as long as the inference procedure between the fuzzy rules. In our approach, the minimum and maximum operators are used as T and S norms

Methodology for the automated creation of fuzzy expert systems [49]; thus the crisp conditions are transformed to fuzzy ones: 9 8 f > croot ?aroot ; u1;root ; u2;root ?; > > > = < f f f Condi ?A; Q ? ? min cn j ?an j ; u1;n j ; u2;n j ?; . . . ; ; (5) > > > > ; : ? a ; u ; u ? cf n 1 ; n 2;nk nk k k where Qf ? fu1;root ; u2;root ; u1;1 ; u2;1 ; . . . ; u1;nt ; u2;nt g is a vector containing all parameters used in the fuzzy model. We de?ne a rule evaluation metric, the likelihood ratio, in order to measure how ‘‘strong’’ a rule is [40]:   ny X fri; j pi ? 2 fri; j log ; (6) ei; j j?1 where ny is the number of classes, fri,j is the observed frequency of class j records, which are covered by a rule Condi(A, Q) ! y, and ei,j is the expected frequency of a rule that makes random predictions. A large pi suggests that the number of correct predictions made by the rule is signi?cantly larger than that expected by random guessing. Other metrics for rule evaluation could be considered, however this was preferred since it takes into account both the accuracy and the coverage of the rules. This metric is applied to each Condf i . Having p ? ? p1 ; p2 ; . . . ; pnc ? f f and Condf ? ?Condf 1 ; Cond2 ; . . . ; Condnc ? the general crisp rules are transformed to fuzzy ones:
f f T Rf y ?A; Q ? ? maxfdiagf p Cond gg;

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Figure 2 Optimization parameters for the fuzzy membership function (sigmoid — increasing).

then the cost function, used for the optimization, is de?ned as ny 1 X X i;i : (10) F ?Q; Dtrain ? ? 1 ? jDtrain j i?1 The optimization method used is the Healed Topographical Multilevel Single Linkage (HTMLSL) [50], a stochastic algorithm based on MLSL. The algorithm attempts iteratively to ?nd all local minima of an objective function F (x) inside a bounded set S & Rn , which are potentially global. These local minima are obtained by a local-search procedure, starting from suitably chosen points in a properly maintained sample. At the kth iteration: 1. Construct a sample selecting at random N points from S and evaluate the objective function at each point; 2. Choose from the sample a subset of points to be used as starting points for local searches; 3. Perform a local search from each starting point. If a new minimum is discovered store it; 4. Determine whether to stop or not. If not, repeat, starting from step 1. From the stored local minima the one with the lowest value is considered to be the global minimum. An example of the proposed methodology is presented in Appendix A.

(7)

where nc is the number of conditions (cond). Eq. (7) de?nes the inference procedure between the fuzzy conditions of the same class. These fuzzy general rules comprise the fuzzy model:
f Mf ?A; Qf ? ? arg max ?Rf y ?A; Q ??: y ?1;...;ny

(8)

As it is shown in Eq. (8), for each feature vector A, the fuzzy general rule with the higher value de?nes its class. Eq. (8) de?nes the defuzzi?cation procedure.

2.3. Fuzzy model’s parameters optimization
The fuzzy model Mf(A, Qf) is optimized with respect to its parameters Qf, using a training dataset (Dtrain). For every conjunct, a parameter u1 (analogous to the slope w) and the centre u2 of the fuzzy membership function (sigmoid) are optimized (Fig. 2). If X is the normalized confusion matrix: X Mf ?A;Qf ?;y ? of patterns in y classified to M ?A; Q ? ; total of patterns in y (9)
f f

3. Datasets
To create the initial set of rules an annotated dataset is needed. In this work, we have tested the proposed methodology, using two widely known

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Figure 3 The features extracted from the recordings for ischaemic beat detection: (a) ST segment deviation, ST segment slope and T wave amplitude (b) ST segment area and QT interval.

medical problems: the ischaemic and arrhythmic beat classi?cation. Two benchmark databases were used, the European Society of Cardiology (ESC) ST-T database [51] and the MIT-BIH arrhythmia database [52].

3.1. Signal pre-processing
In some cases, ECG recordings contain signi?cant amount of noise. In order to detect all the relevant ECG characteristics needed to estimate the subsequent features, noise handling must be performed. The QRS complex, which is the most prominent wave in the ECG, is detected for every cardiac beat using the QRS detection method proposed by Tompkins [53,54]. Then, pre-processing of the recorded ECG signal is performed (separately for each lead) in order to eliminate noise distortions (e.g. baseline wandering, A/C interference and electromyographic contamination). Noise elimination is achieved by ?ltering each recorded cardiac beat separately [16]. Baseline wandering is removed by subtracting from the recorded signal the ?rst-order polynomial that best ?ts the cardiac beat. A/C interference and electromyographic contamination are not removed from the recorded signal but are handled properly for the detection of the J point. More speci?cally, for these two types of noise, a 20 ms averaging ?lter was applied around J point. The exact location of the J point is detected using a technique based on an edgedetection algorithm [55].

recordings. These 10 recordings are selected because their ischaemic ECG beats are characterized by signi?cant waveform variability. Three medical experts annotated independently each beat as normal, ischaemic or artefact. In case of disagreement the three medical experts reviewed the relevant beat and a decision was taken by consensus. After removing the artefacts and the misdetected beats, the ?nal dataset contained 76,989 cardiac beats, diagnosed as normal or ischaemic. Several features were extracted from each cardiac beat (Fig. 3). These features were selected according to expert cardiologists [8,44,56]:  The ST segment deviation (Fig. 3a) refers to the amplitude deviation of the ST segment from the isoelectric line, which is the line de?ning the level of zero amplitude. The ST segment changes are measured either 80 ms after the J point (J80) (heart rate 120 bpm), or 60 ms after the J point (J60) (heart rate > 120 bpm). Following the ESC recommendations [57] the STsegment deviation is measured relative to a reference waveform for each subject. The reference waveform is calculated using the ?rst 30 s of each recording and is computed by the mean value of the ST segment deviations at this interval respectively.  The ST segment slope (Fig. 3a) is the slope of the line connecting the J and J80 (or J60) points.  The ST segment area (Fig. 3a) is the area between the ECG trace, the isoelectric line and the points J and J80 (or J60).  The T-wave amplitude (Fig. 3b) is the amplitude deviation of the T-wave peak from the isoelectric line. Similarly with the ST segment deviation, the T wave amplitude is measured relative to a reference waveform for each subject which is selected from the ?rst 30 s of each database record.  The QT interval (Fig. 3b) which is the interval from the beginning of the Q wave (Qonset) to the end of

3.2. Ischaemic beat classi?cation dataset
In order to construct the dataset for training and testing the ischaemic FES, 11 h of two-channel ECG recordings from the ESC ST-T database [51] are used. Those, contain the whole e0104 recording and the ?rst hour of the e0103, e0105, e0108, e0113, e0114, e0147, e0159, e0162, and e0206

Methodology for the automated creation of fuzzy expert systems

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Figure 4

Heart rate variability (HRV) signal (tachogram).

the Twave (Toffset). The beginning of the Q wave is determined using the edge detection algorithm mentioned before. For the detection of the T wave end, a 5th order polynomial is ?tted to the interval between the peak of the T wave and 0.3*RR seconds after it. Based on the derivative of the ?tted function, we can detect the Toffset [58]. In order to handle properly the biphasic T waves, a rule followed by Daskalov and Christov [59] has also been considered. Furthermore, the obtained QT has been corrected using an ef?cient QT correction formula, based on the heart rate variability [45]. The above QT delineator has been tested in the CSE database [60] and reported comparable performance with the method of Daskalov and Christov [59]. In addition to these features a sixth one, the age of the patient, is used. All the above features are considered very relevant for the detection of ischaemic beats. These features are used to create the dataset: Disch = {dl, cl} with dl, the lth feature vector and cl the class of the beat. The class cl is represented as cl 2 {0, 1}2, i.e. cl = [0, 1] if the beat is normal and cl = [1, 0] if the beat is ischaemic.

rhythm patterns, and thus being important for the classi?cation process. The functions have been proposed by expert cardiologists and have been used in previous research attempts [24,27]. The class cl is represented as cl 2 {0, 1}4, where, if dl belongs to class i, then cl = ei. Both rhythm and beat annotations from the database are used to specify the class, following the scheme: if RR2 is annotated as ventricular ?utter/?brillation (VF), then cl = [1, 0, 0, 0], else if RR2 is annotated as premature ventricular contraction (PVC)1 then cl = [0, 1, 0, 0], else if RR2 belongs to 28 heart block episode (BII), then cl = [0, 0, 0, 1], else RR2 is considered as normal (N) and cl = [0, 0, 1, 0]. The above resulted in 109,880 beats.

4. Results
In the case of ischaemic beat detection, from the 76,989 beats, we used 1936 beats (954 ischaemic and 982 normal) for training the ischaemic FES and the rest 75,053 (36,709 ischaemic and 38,344 normal) beats for testing it (Table 1). The sampling of the 76,989 beats for acquiring the training ones was performed by selecting iteratively the ?rst beat out of a sequence of 40 ones. In this way, beats from all recordings were used both for training and testing (global training). For training and testing the arrhythmic FES, we followed a different strategy due to the large imbalance in the distribution of classes. In order to select training and test sets in highly imbalanced datasets, three approaches can be followed: oversampling, undersampling or hybrid sampling. However, both oversampling and hybrid sampling tend to give over?tted models [40]. For this reason, in order to train the arrhythmic FES, undersampling was employed. Three hundred beats from each category, randomly selected, were used for training the arrhythmic FES (1200 beats) and the remaining beats from all categories for testing it (108,680 beats). Table 1 presents
1

3.3. Arrhythmic beat classi?cation dataset
For training and testing the arrhythmic FES, all beats from all records from the MIT-BIH arrhythmia database [52] are used for the creation of the dataset. Having detected the R waves, the tachogram (Fig. 4) is extracted measuring the time intervals between consecutive R waves. A three RR interval sliding window, is used (RR1, RR2, RR3) as well as functions of those intervals, to create the dataset Darrh = {dl, cl} with dl = (RR1, RR2, RR3, RR1 + RR2 + RR3, RR1/ RR2, RR3/RR1, RR3/RR2, jRR1 ? RR2j, jRR2 ? RR3j, 2RR3)/(RR1 + RR2), 2RR1/(RR2 + RR3), the lth feature vector and cl the class of the middle RR interval (RR2). These functions provide useful information of the non-linear relations between the three consecutive RR intervals, related to speci?c cardiac

Isolated PVCs, as well as, runs of PVCs are included.

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Table 1 Number of beats used for training and testing the FESs for ischaemia and arrhythmia Disease Ischaemia Classes Ischaemic Normal Overall VF PVC N BII Overall Train 954 982 1936 300 300 300 300 1200 Test 36,709 38,344 75,053 184 5,883 102,493 120 108,680

T.P. Exarchos et al.

Overall 37,663 39,326 76,989 484 6183 102,793 420 109,880

Arrhythmia

the training and test sets for each class. As it is mentioned above, the training beats were used both for the crisp model development and the parameter optimization. The above-described datasets are used to evaluate our methodology. In the ?rst stage of the methodology, the set of rules extracted from the decision tree consists of 53 rules (ischaemic FES), from which

27 predicted normal beats and the rest 26 predicted ischaemic beats. In the case of the arrhythmic FES, 17 rules are generated: 2 of them have as consequent the VF category, 7 the PVC category, 7 the N category and one rule predicted the BII category (Table 2). Indicative crisp rules from both application domains are presented below (one rule for each class of the classi?cation problems):

Indicative rules for Ischaemia2 8 9 ST segment area > 0:9705 AND ST segment area 1:6802 AND > > > > < = T wave amplitue > ? 0:1917 AND T wave amplitude 0:218 AND if ST segment slope > 53:45 AND > > > > : ; Age > 47 AND Age 65 then {Beat is Isch} 8 9 T wave amplitude > ? 1:3307 AND T wave amplitude 0:1628 AND > > > > < = ST segment area > ? 0:7349 AND ST segment area 0:9705 AND if > ST segment deviation > ? 0:0103 AND QT interval 1:427 AND > > > : ; Age > 60 AND Age 62 then {Bean is Norm} Indicative rules for Arrhythmia   RR2 1:464 AND thenfBeat is VF g if RR1 ? RR2 ? RR3 1:377 8 9 < RR1 ? RR2 ? RR3 > 1:377 AND = if RR2 > 0:358 AND RR2 0:656 thenfBeat is PVCg : ; RR3 =RR1 > 1:1484 AND 9 RR2 1:464 AND > > > > RR3 =RR1 1:1484 AND = thenfBeat is Ng RR3 =RR1 > 1:1484 AND if > > > 2RR3 =?RR1 ? RR2 ? 1:14173 AND > > > > > : ; RR1 ? RR2 ? RR3 > 1:722 if {RR2 > 1.461} then {Bean is BII}
2

8 > > > > <

ST segment deviation and T wave amplitude are measured in millivolt, ST segment slope is measured in degrees, ST Segment area in milivolt seconds, QT interval and RR interval in seconds and age is measured in years.

Table 3 displays the normalized confusion matrix for ischaemic beat classi?cation, performed using only the initial set of rules extracted from the decision tree. The obtained sensitivity (Se) and speci?city

Methodology for the automated creation of fuzzy expert systems
Table 2 Number of rules extracted from the decision trees for ischaemia and arrhythmia FESs Disease Ischaemia Classes Ischaemic Normal Overall VF PVC N BII Overall No. rules 26 27 53 2 7 7 1 17

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Arrhythmia

Table 3 Confusion matrix, sensitivity (Se) and speci?city (Sp) for ischaemic beat detection using only the 1st stage (decision tree) and the ischaemic FES First stage only classi?ed as Isch Database Isch Norm Metrics (%) Se Sp Acc 0.907 0.100 90.7 90.0 90.4 Norm 0.093 0.900 Three-stage methodology classi?ed as Isch 0.912 0.078 91.2 92.2 91.7 Norm 0.088 0.922

(Sp) are 90.7% and 90%, respectively. In addition, Table 3 presents the normalized confusion matrix for the ischaemic FES; in the latter, the sensitivity and speci?city are increased to 91.2% and 92.2%, respectively. The application of the methodology in the ischaemic beat detection problem misclassi?ed 3226 ischaemic and 2989 normal beats. Table 4 presents the normalized confusion matrix for arrhythmic beat classi?cation, again employing only the initial set of rules and then using the three stage methodology (arrhythmic FES). Using only the

initial set of rules, the sensitivity and speci?city is 97.3% and 98.8% for the VF category, 89.1% and 96.6% for the PVC category, 91.9% and 97% for the N category, 98.3% and 99.8% for the BII category, respectively. The above results are improved when all stages of the methodology are used. More speci?cally, the sensitivity and speci?city is 98.9% and 99.3% for the VF category, 92.4% and 97.6% for the PVC category, 93.6% and 97.7% for the N category, 98.3% and 99.9% for the BII category, respectively. The results for the VF and BII categories are very high, while there is high misclassi?cation rate between the PVC and N categories; 362 PVC beats were misclassi?ed as N (6.15%) and 5453N beats were misclassi?ed as PVC (5.32%). From the obtained results it is clear that the application of the proposed methodology improved the ef?ciency of the induced decision trees, for both ischaemic and arrhythmic beat classi?cation. The ischaemic FES improved the accuracy of the decision tree by 1.3%, while the respective improvement for the arrhythmic FES is 1.6%. The number of beats in the test set is suf?ciently large, thus the error rates, de?ned as: e = 1 ? acc, of the decision trees and the FESs in both cases (i.e. ischaemic and arrhythmic beat classi?cation) can be approximated using normal distributions [40]. If the observed difference in e is de?ned as d = jeFES ? eDTj, where eFES is the error rate of the FES and eDT is the error rate of the decision tree, then d is also normally distributed, with variance: s 2 d ? ?accDT ?1 ? accDT ? ? accFES ?1 ? accFES ??=N, where N the number of test records (i.e. number of beats), accDT is the accuracy of the decision tree and accFES is the accuracy of the FES. At 95% con?dence level, the upper bound for the standard normal distribution is 1.96 and thus, the con?dence interval for the true difference dt is: dt = d ? 1.96sd. For ischaemic beat classi?cation, the con?dence interval for dt at 95% con?dence level is

Table 4 Confusion matrix, sensitivity (Se) and speci?city (Sp) for all categories of the arrhythmic beat classi?cation using only the 1st stage (decision tree) and the arrhythmic FES First stage only classi?ed as VF Database VF PVC N BII 0.973 0.026 0.009 0.000 PVC 0.027 0.891 0.065 0.008 89.1 96.6 94.2 N 0.000 0.083 0.919 0.008 91.9 97.0 BII 0.000 0.000 0.006 0.983 98.3 99.8 Three-stage methodology classi?ed as VF 0.989 0.014 0.006 0.000 98.9 99.3 PVC 0.011 0.924 0.053 0.008 92.4 97.6 95.8 N 0.000 0.062 0.936 0.008 93.6 97.7 BII 0.000 0.000 0.004 0.983 98.3 99.9

Metrics (%) Se 97.3 Sp 98.8 Acc

196 1.3 ? 0.43, which does not spam the zero value and thus the observed difference is statistically signi?cant. Similarly, for arrhythmic beat classi?cation, the con?dence interval for dt at 95% con?dence level is 1.6 ? 0.32, which also does not spam the zero value and thus the observed difference is statistically signi?cant.

T.P. Exarchos et al. current work we employed decision trees with the C4.5 algorithm which is widely used and is considered as a very effective approach for classi?cation. Also, the introduction of the fuzzy models addresses the uncertainty inherent in several medical problems [30]. The development of the fuzzy model from the initial set of rules and the optimization of its parameters improves the ef?ciency of the decision tree. Thus, in the case of ischaemic beat detection, the performance (accuracy) is improved by 1.3% and in the case of arrhythmic beat classi?cation the performance is improved by 1.6%. Finally, representative features from the cardiac beats are extracted and they are used for both FESs: features from the ST-T interval, which is of known ischaemic diagnostic value, are used for ischaemic beat detection while features from the tachogram, which is appropriate to characterize the types of arrhythmias that are under consideration in this study [27], are employed for arrhythmic beat classi?cation. In what concerns ischaemic beat detection, in Table 5 the results of the proposed ischaemic FES are compared to those of other similar approaches; our approach shows slightly better performance. These methods were tested using data form the ESC ST-T database, which is a standard reference for myocardial ischaemia detection [2,3]. However, some of the results reported in the literature refer to different subsets of ECG recordings of the ESC ST-T database [10,11,13] or have used different databases for their evaluation [5,6], and thus, their performance cannot be directly compared. It should be noted that in Ref. [13] a different subset of the ESC ST-T database was employed to evaluate the ischaemic beat classi?er. More speci?cally, it was considered that each annotated episode in the database contains only ischaeamic beats. In addition, most of these techniques are based on neural or signal processing approaches; such methods exhibit a serious drawback compared to our rule-based approach, due to

5. Discussion
In this study, we propose a methodology for the automated creation of fuzzy expert systems that consists of three stages: (i) extraction of a set of rules using a decision tree, (ii) transformation of the set of rules into a fuzzy model, and (iii) optimization of the fuzzy model’s parameters using global optimization. The proposed methodology has been evaluated in the detection of ischaemic cardiac beats in ECG recordings using data from the ESC ST-T database. Also, it has been evaluated in arrhythmic beat classi?cation, using data from the MIT-BIH arrhythmia database. In both cases high classi?cation results were obtained; the accuracy (Acc) is 92% and 96% for the ischaemic and arrhythmic FES, respectively. The proposed methodology is innovative since it combines data mining techniques with fuzzy modelling and introduces several novelties. It is generic and thus it can be applied to any classi?cation domain; given an initial annotated dataset, it can automatically generate a FES. This FES is based on a set of fuzzy rules and thus it is able to provide interpretation for its decisions. This is a highly desirable feature, since the ability to explain the reason for a decision is of great value for the domain experts. In addition, the employment of data mining (decision trees) in the ?rst stage of the methodology has the advantage of discovering new knowledge [40,41]. It should me mentioned that the proposed methodology can incorporate in the ?rst stage any rule mining technique. In the

Table 5 Comparison of the performance of several methods for ischaemic beat detection evaluated using the ESC STT database Method Rule-based [7] ANN & PCA [9] Bidirectional associative memories ANN [10] ANN (classi?cation partitioning-SOM & SVM) [11] Feed forward ANN and nonlinear PCA [13] Multicriteria decision analysis [14] Genetic algorithms & multicriteria decision analysis [15] Association rule mining [16] Current work Se (%) 70 90 Sp (%) 63 90 56 80 79 90 91 87 91 75 89 91 93 92 Acc (%)

90 92

Methodology for the automated creation of fuzzy expert systems
Table 6 Comparison of the performance of several methods for arrhythmic beat classi?cation evaluated using the MIT-BIH arrhythmia database Method PCA & mixture of experts approach (SOM, LVQ) [18] Hermite functions & SOM [19] Discrete wavelet transform & intersecting spheres network [20] Second, third and fourth order cumulants & hybrid ANN [22] Autoregressive modelling [23] SVM [25] ECG morphology & linear discriminates [26] Knowledge-based system [27] Current work Acc (%) 95.5 98.5 96 96 97 96 97.5 94 96

197

their inability to provide clear and direct explanations for their classi?cation decisions [61]. This is of great importance when developing medical decision support systems that will assist physicians in the diagnosis. Table 6 presents several methods proposed in the literature for arrhythmic beat classi?cation, along with the reported accuracy. The accuracy obtained from those methods is in the range from 94% to 98.5%. The methods reported in Refs. [18— 23,25] are based on ‘‘black box’’ approaches, such as neural networks and support vector machines. Therefore, there is no exact interpretation for their results [61]. In our approach each decision can be interpreted in a medical manner. In the proposed methodology, only QRS detection was performed, on the ECG signal and the analysis is based on the RR intervals. Several of the methods proposed in the literature are based on the analysis of the ECG signal (Dokur et al. [20], Osowski et al. [22,25], Hu et al. [18], Lagerholm et al. [19]), which is much more time-consuming than the proposed method. Also, it is advantageous compared to other approaches which use morphological ECG features [26], which are not feasible in cases of high noise. In [18] initial labelling of the beats was required and there was no automatic QRS detection–—the points of the database annotation were used. The method was evaluated using the last 25 min of the records in the 200 series, apart from records 212, 217, 220, 222 and 232. In Ref. [19] all MIT-BIH arrhythmia database records were used for evaluation but the primary objective was to perform clustering with an expert performing the ?nal beat classi?cation. In the present work four beat categories are automatically classi?ed, without any human interference, in

contrast to Refs. [18,19]. In addition, some of the proposed methods have been tested on small subsets of the MIT-BIH arrhythmia database [20,22,23,25], while our results were obtained using all records from the MIT-BIH arrhythmia database for evaluation. A limitation of our methodology is the requirement of a representative training set in order to extract reliable rules and thus create a reliable fuzzy model. In addition, the utilization of decision rules for classi?cation, besides ?nding valid, causal relationships in the clinical data, will also ?nd all of the spurious and particular relationships among the data in the speci?c dataset. For this reason, results of any data mining procedure should be considered as exploratory and hypothesis-generating. Regarding the arrhythmic beat classi?cation problem, the RR interval signal was used, thus limiting the arrhythmic categories to only those that affect the physiological RR intervals. Future work will also include other types of arrhythmias, i.e. atrial arrhythmias. Since the proposed methodology is generic, different approaches can be employed for all three stages. Future work will focus on the use of other rule mining techniques (C5.0, association rule mining), different de?nition of the fuzzy model (other fuzzi?cation functions, inference engines and defuzzi?cation approaches) and employment of alternative optimization techniques (global or local).

6. Conclusions
We presented a novel methodology for the automated creation of FESs. The main advantage of the methodology is the combination of high accuracy with the ability to provide interpretation for the decisions made. The generated FESs for ischaemic and arrhythmic beat classi?cation compare well with previously reported results, indicating that they could be part of an overall clinical system for ECG analysis and diagnosis. However, more clinical testing is needed in order to be fully evaluated.

Acknowledgments
This research is part funded by the program ‘‘Heraklitos’’ of the Operational Program for Education and Initial Vocational Training of the Hellenic Ministry of Education under the 3rd Community Support Framework and the European Social Fund.

198

T.P. Exarchos et al.

Appendix A
In this appendix we provide a working example of our methodology. In the ?rst stage, having the initial annotated dataset, with three features (nf = 3): A = {a1, a2, a3} and two classes ((ny = 2)), we create a decision tree, parse it and create the following set of rules: if?a1 > u1 ^ a2 u2 ? then c ? 1; if?a2 > u3 ^ a3 u4 ? then c ? 1; if?a1 > u5 ^ a3 > u6 ? then c ? 2; where Q = {u1, u2, u3, u4, u5, u6} is the vector containing all thresholds used in the tree (without loss of generality we have not included aroot and uroot). The crisp model contains three conditions:
dec Cond1 ?A; Q? : ?ginc c ?a1 ; u 1 ? ^ gc ?a2 ; u 2 ??; dec : ?ginc c ?a2 ; u 3 ? ^ gc ?a3 ; u 4 ??; inc : ?ginc c ?a1 ; u 5 ? ^ gc ?a3 ; u6 ??;

with Cond1 ?A; Q? ! 1; with Cond2 ?A; Q? ! 1; with Cond3 ?A; Q? ! 2:

Cond2 ?A; Q? Cond3 ?A; Q?

Therefore, the crisp model contains two general crisp rules (one for each class):
dec inc dec R1 ?A; Q? ? ?ginc c ?a1 ; u1 ? ^ gc ?a2 ; u2 ?? _ ?gc ?a2 ; u3 ? ^ gc ?a3 ; u4 ??; inc R2 ?A; Q? ? ?ginc c ?a1 ; u5 ? ^ gc ?a3 ; u6 ??:

In the second stage, the fuzzy model is created, fuzzifying the crisp conditions:
f inc dec Condf 1 ?A; Q ? : min?gs ?a1 ; u1;1 ; u2;1 ?; gs ?a2 ; u 1;2 ; u 2;2 ??; dec : min?ginc s ?a2 ; u1;3 ; u2;3 ?; gs ?a3 ; u 1;4 ; u 2;4 ??; inc : min?ginc s ?a1 ; u1;5 ; u2;5 ?; gs ?a3 ; u1;6 ; u2;6 ??; f Condf 2 ?A; Q ? f Condf 3 ?A; Q ?

and thus, the general fuzzy rules are:   ?a1 ; u1;1 ; u2;1 ?; gdec ?a2 ; u1;2 ; u2;2 ??; p1 min?ginc f f s s R1 ?A; Q ? ? max ; dec p2 min?ginc s ?a2 ; u1;3 ; u2;3 ?; gs ?a3 ; u 1;4 ; u 2;4 ??
inc ? p3 min?ginc s ?a1 ; u1;5 ; u2;5 ?; gs ?a3 ; u1;6 ; u2;6 ??;

f Rf 2 ?A; Q ?

with Qf = {u1,1, u2,1, . . ., u1,6, u2,6} being the parameter set of the fuzzy model and p = [p1, p2, p3] the likelihood ratio of each rule. The fuzzy model is then created as follows:   1 0 ?a1 ; u1;1 ; u2;1 ?; gdec ?a2 ; u1;2 ; u2;2 ??; p1 min?ginc s s f @ max p min?ginc ?a2 ; u1;3 ; u2;3 ?; gdec ?a3 ; u1;4 ; u2;4 ?? ; A: Mf ?A; Qf ? ? arg max ?Rf y ?A; Q ?? ? arg max 2 s s y ?1;...;ny inc p3 min?ginc s ?a1 ; u1;5 ; u2;5 ?; gs ?a3 ; u1;6 ; u2;6 ?? Finally, in the third stage, Mf(A, Qf) is optimized with respect to Qf and the fuzzy expert system is de?ned as follows: 0 ! 1 p1 min?ginc ?a1 ; u? ; u? ?; gdec ?a 2 ; u ? ; u? ??; s 1 ; 1 2 ; 1 s 1 ; 2 2 ; 2   ;C B max ? ? dec ? ? C; Mf ?A; Qf? ? ? arg maxB p2 min ginc s ?a2 ; u1;3 ; u2;3 ?; gs ?a3 ; u 1;4 ; u 2;4 ? @ A
? ? inc ? ? p3 min?ginc s ?a1 ; u1;5 ; u2;5 ?; gs ?a3 ; u1;6 ; u2;6 ?? ? ? ? where Qf? ? fu? 1;1 ; u2;1 ; . . . ; u1;6 ; u2;6 g is the set of the optimized parameters.

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