Method and Apparatus for Analyzing Electrocardiographic Signals

This invention relates to electrocardiography and, more particularly, to a method and apparatus for predicting risk for development of malignant ventricular arrhythmias.

Many patients who have suffered heart damage via a myocardial infarction are in danger of sudden death from acute arrhythmia. The ability to reliably and noninvasely predict the risk for development of such arrhythmias in patients is desirable.

Recently high gain amplification and signal processing techniques in the time domain have detected low amplitude, high frequency potentials in the terminal QRS complex and ST segments of signal averaged electrocardiograms (ECG's) obtained during arrhythmia free intervals from patients and experimental animals with sustained ventricular tachycardia. Recent studies of these patients with time domain analysis have used a variety of low (25 to 100 Hz) and high (250 to 300 Hz) band pass filters. A major limitation of these time domain procedures is the lack of a priori knowledge of the frequency distribution of the signals of interest and hence the inherent risk that filtering will exclude signals of particular interest. Fast Fourier Transform (FET) analysis is a powerful analytic method that is complimentary to time domain analysis and avoids some of the limitations of a priori filtering. Moreover, FET analysis facilitates identification and characterization of frequencies independent of regional amplitude and is thus particularly well suited for assessing low amplitude signals. Finally, this system and FET analysis provide flexibility for analyzing different ECG regions using the same system hardware and software.

As another example of time domain analysis, U.S. Pat. No. 4,442,459 (Simson) discloses applying the latter portions of the X, Y, and Z digital QRS signals in reverse time order to a digital high pass filter to eliminate a ringing artifact from the filter output. The resulting filtered outputs are combined to create a filtered QRS which is examined and the last 40 milliseconds of which is isolated and measured to obtain an indication of the level of high energy content. The initial portion of the QRS wave form is also processed in a forward direction to obtain an indication of the QRS total duration.

An object of the present invention is to provide a noninvasive electrocardiographic system capable of improved objective identification and characterization of low amplitude potentials in the surface ECG signal.

The X, Y, and Z ECG signals are amplified, recorded over a broad bandwidth, converted from analog to digital, processed to select normal QRS waveforms, and signal averaged to reduce the noise level. A fast Fourier transform is then performed on the terminal 40 milliseconds of the QRS complex and ST segments of each of the averaged X, Y, and Z ECG signals. The resultant spectral outputs are examined and a figure of merit created to obtain a characterization of the frequency content of the various portions of the signal averaged ECG examined.

In one embodiment the magnitude of the FFT is first squared to form energy spectra of the ECG signals. An energy measure of a first preselected portion such as the 20 to 50 Hz region is compared with an energy measure of a second preselected portion such as the entire energy spectra to determine the presence or absence of a predetermined frequency content in a predetermined portion of the ECG signals such as the combined QRS terminal 40 milliseconds and ST region. The comparison includes taking the magnitudes of the peaks in the first preselected portion of a spectrum and comparing them with the magnitude of the largest peak of the spectrum. Also the area under the spectrum curve in the first preselected portion is compared with the area of the 0 to 20 Hz region.

The peak magnitude and area comparisons after further operation are called the magnitude ratio and area ratio. Since a plurality of ECG leads are used with each patient when monitoring the ECG, a mean value formed from all ECG leads for the magnitude ratio and area ratio is formed for each patient.

FIG. 1 is a block diagram of a preferred embodiment of the present invention.

FIG. 2A is a representative signal averaged ECG from one of the leads of FIG. 1 showing various segments of the ECG signal and the R--R interval.

FIG. 2B is a spectral plot of the FFT of the terminal QRS segment of FIG. 2A.

FIG. 3 is a flow chart of the method used for template formation.

FIG. 4 is a simplified flow chart of the program for selecting and averaging ECG signals.

FIG. 5 is a flow chart of the program used for characterizing the frequency content of the averaged ECG signals generated by FIG. 4.

FIGS. 6A through 6F represent the outputs of the program of FIG. 5 operating on a first segment of averaged X, Y and Z ECG signals from a patient with prior myocardial infarction without sustained ventricular tachycardia (VT) and a patient with prior myocardial infarction with sustained VT.

FIGS. 7A through 7F represent the outputs of the program of FIG. 5 operating on a second segment of averaged X, Y and Z ECG signals from a patient with prior myocardial infarction without sustained ventricular tachycardia (VT) and a patient with prior myocardial infarction with sustained VT.

FIG. 8 is a flow chart of an alternate program to that of FIG. 5 used for characterizing the frequency content of the averaged ECG signals generated by FIG. 4.

FIG. 9 is a representative signal averaged ECG from one of the leads of FIG. 1 showing the combined terminal QRS and ST segment of the ECG signal.

FIG. 10 is a sample energy spectra plot of the signal of FIG. 9 showing the main peak as a solid line on a first scale as marked on the left side and the secondary peaks as a dashd line on a second scale on the right side.

FIGS. 11A through 11F represent the outputs of the program of FIG. 8 operating on a first segment of averaged X, Y and Z ECG signals from a patient with prior myocardial infarction without sustained ventricular tachycardia (VT) and a patient with prior myocardial infarction with sustained VT.

FIGS. 12A through 12F represent the outputs of the program of FIG. 8 operating on a segment of averaged X, Y and Z ECG signals from a patient with prior myocardial infarction without sustained ventricular tachycardia (VT) and a different patient from the patient of FIGS. 11A through 11F with prior myocardial infarction with sustained VT.

FIG. 13 is a graph comparing the mean area ratios of patients from Groups I, II and III.

FIG. 14 is a graph comparing the mean magnitude ratios vs. frequency for patients from the Groups I, II, and III.

Referring now to FIG. 1, a block diagram of the present invention designated generally 100 is shown including standard bipolar X, Y, and Z electrocardiogram (ECG) leads 102, 104, and 106, respectively. Standard Frank X, Y, and Z leads, Model No. 1507-11A, are applied to a patient in accordance with the Model 1507-11A recommended electrode placement. Each of the X, Y, and Z lead signals are amplified (1,000 fold) by Hewlett-Packard 1057 Amplifiers 110, 112, and 114, respectively. The outputs of the amplifiers are passed through band pass filters 116, 118, and 120, respectively, having a bandwidth of 0.05 Hz to 470 Hz. Then the signals are converted from analog to digital signals by A/D converter 122 at a 1 KHz rate having 12 bits of accuracy and a lowest resolution of 1 microvolt. An ADAC Inc. Model No.16SE-C-3P6A-P A/D converter was used.

The input to the A/D converter 122 is switched sequentially among the outputs of filters 116, 118 and 120 with a 300 microsecond delay in between. The digital X, Y and Z signals from A/D converter 122 are provided in parallel over line 130 to microcomputer 150. A floppy disk memory 152 and a Selanar raster graphics display 154 with raster control are coupled to the microcomputer 150. A DEC VT 103 LSI 11/23 microcomputer with 64K bytes of memory was used. The microcomputer 150 along with disk 152 and display 154 can be mounted on a portable cart for use at the patients bedside. The amplified X, Y, and Z signals are simultaneously displayed on the Hewlett-Packard oscilliscope 160 for continuous real time visual monitoring.

Referring now to FIG. 2A, a representative signal averaged Z ECG lead designated generally 200 is shown. Two QRS complexes designated generally 202 and 204 are shown. The large signal 206 is known as the R wave, and its peak 208 is called the fiducial point. The time separation between adjacent R waves 206 and 210 is called the R--R interval. The peak to peak amplitude of the QRS signal is the voltage measured from the positive peak of the R wave at 208 to the negative peak of the QRS waveform at 212.

Each ECG signal can be thought of as including: a terminal QRS signal 214 which comprises the last 40 msec of the QRS complex (end of QRS complex and preceding 40 msec); and an ST segment 216 which extends from the end of the QRS segment 214 to the beginning of the T segment 218 of the ECG signal 200.

Referring now to FIG. 3, a simplified block diagram for template formation designated generally 300 is shown for selecting certain ones of the digital X, Y, and Z signals which are to be considered as arrhythmia-free signals and which are to be used in forming the signal averaged X, Y, and Z ECG signals for further processing. By visual inspection of the display 160, a set of X, Y, and Z signals is chosen which can be considered to represent a display of normal sinus rhythm 302. The signal such as the one having the largest R wave amplitude relative to the P and T points of the ECG signal is selected 304. Then a three second sample of the X, Y and Z leads are digitized and stored 306. The preselected signal 304 is displayed on display 154. See 308. The R--R interval (the distance between adjacent R waves of adjacent QRS complexes) and the fiducial point (peak point 208 of the R wave) are identified using the adjustable cursor accompanying the Selanar display 310. At the same time the QRS amplitudes (peak to peak voltages) for each of the X, Y, and Z signals are determined 314. The R--R interval, fiducial point 208, the X, Y, and Z QRS amplitudes and 40 points of the R waves (20 points on either side of the fiducial point) are then stored at a template in the mini-computer 150 memory. This is done automatically using the DEC graphics software package in combination with the use of the cursors on display 154.

Referring now to FIG. 4 a process designated generally 400 for selecting arrhythmia free X, Y and Z signals and for averaging ECG signals is shown. Once again, a three second sample of the heartbeat is chosen, digitized, and the digitized X, Y, and Z signals for the three second interval are stored in a circular memory buffer. See 402. The middle beat of these stored three second samples is chosen 404 and the selected signal compared with the template. Specifically, the R--R interval is compared with the template R--R interval 406. If the R--R interval is not within .+-.20% of the template value the beat is rejected. See 408. Otherwise, the peak to peak amplitudes of the X, Y, and Z signals of the chosen beat are compared with the QRS amplitudes of the template 410. If at least 2 of the 3 amplitudes are the same as the template amplitudes then the beat is selected as a candidate for averaging, otherwise the beat is rejected 412. Then a 40 point cross correlation 414 of the R wave is made with the template waveform about the fiducial point 208. The 40 points which are chosen are 20 points lying on either side of the fiducial point. If the correlation coefficient is not greater than 98% the beat is rejected 416. If the beat passes the amplitude and cross correlation comparisons, then for the current beat to be acceptable, the beat which went before it and the beat which follows it must all be found to be acceptable when compared with the R--R template. If the center beat is found to be unacceptable then it is shifted left in the circular buffer and compared to the next beat. This process goes on in real time and only if buffer overflow occurs do you go back to 404. The X, Y, and Z ECG signals of each acceptable beat are averaged, point by point, with the X, Y, and Z ECG signals of all other acceptable beats until a 100 beat average is created 418.

The above description of the operation of FIG. 4 is done automatically using the FORTRAN program No. 1 (pages 20-25).

Referring now to FIG. 5, a fast Fourier transform (FFT) analysis 500 is performed on the terminal 40 milliseconds of the QRS complex for each of the averaged X, Y, and Z signals. All of the averaged X, Y and Z QRS signals are stored in memory 152, e.g., the averaged X, Y and Z signals are displayed on display 154. See 502. Using the display cursors, the terminal 40 milliseconds of the QRS signal is determined 504 by finding the end of the QRS complex and sliding 40 msec into the R wave.

A fast Fourier transform (FFT) 506 is performed on the chosen segment of the ECG signal, for example, on the terminal 40 milliseconds of the QRS complex as defined above. The FFT can be performed using any one of a plurality of acceptable commercially available computer programs suitable for use on the particular minicomputer 150, for example, a FORTRAN program from the standard IEEE Library is acceptable and is hereto employed. For the particular segment of the ECG signal chosen a 512 point fast Fourier transform was calculated. The selected sample values (those selected automatically by the cursor) were placed at the beginning of the 512 input array of the FFT program and the remaining values set to zero. This step permitted maintenance of the same frequency scale in the output data but allowed an arbitrary member of input values up to 512.

Fourier analysis assumes that the signal contained in the sample window interval is a repetitive function. If the initial sample point and final sample point are not isopotential, a sharp discontinuity will be introduced between the end of one cycle and the beginning of the next that will artifactually add both high and low frequencies to the original signal. To eliminate this source of error when performing the FFT on discrete components of the ECG (i.e. the terminal 40 msec of the QRS complex) the segment of intersect is multiplied by a four term Blackman-Harris window function 508 to smooth the data to zero at the boundaries 504. See "On the use of windows for harmonic analysis with the discreet Fourier transform", Harris, F. J., PROC IEEE 66:51, 1978 and the FORTRAN program #2 (pages 26-30). The particular Blackman-Harris function used herein had a 6 dB bandwidth, a 92 dB sidelobe level, and a sidelobe falloff of 6 dB per octave. Multiplication of the Blackman-Harris window must be performed before the FFT is calculated.

The FFT data are plotted with a high resolution plotter (Versatec, Inc.) 510 and transferred to disk 152 for storage. Referring to FIG. 2B, for each plot, the dB drop at 40 Hz 250 is found and the area 252 under the curve from the fundamental frequency to the frequency at which the amplitude of the spectrum plot drops to 60 dB below the peak level (60 dB area) is determined. (See the FORTRAN program No. 3, pages 31-34.) These two values together form a figure of merit (FOM) 512, FIG. 5, for the spectral plot. The 40 Hz intercept was chosen because most of the energy of a normal QRS is less than 35 Hz and because work by others has shown that fragmented signals have a peak frequency in the 25 to 50 Hz range.

The above mentioned steps of FIG. 5 are performed simultaneously on the averaged X, Y and Z signals and three spectral plots are formed. The mean of the 40 Hz intercept and the 60 dB areas of the FOM's for the averaged X, Y and Z signals is calculated for each patient to generate a single 40 Hz intercept and 60 dB area FOM. The process described in connection with FIG. 5 given above was also performed for ST segment 216 of the averaged X, Y and Z ECG signals. It should be remembered that the ST segment 216 is defined as beginning at the end of the QRS complex and proceeding to the beginning of the T wave. The ST segment is defined using the cursor of the Selanar display.

Using the above-mentioned method, 61 patients were grouped according to clinical characteristics. None was currently receiving antiarrhythmic medications. Group I comprised 16 patients with prior myocardial infarction with at least one documented episode of sustained VT or cardiac arrest that was not associated with a new infarct. Each of the 13 of these 16 patients who was studied in the Clinical Electrophysiology Laboratory at Washington University had inducible sustained VT or VF similar to that occurring clinically. Group II consisted of 35 patients with prior myocardial infarction without a history or documented episode of sustained VT (>30 seconds in duration), syncope, or cardiac arrest who were admitted to the Barnes Hospital Telemetry Unit. All patients in this group were monitored for at least 7 days. Seventeen exhibited absent or simple ventricular ectopy (Modified Lown Class 0 to 1); 18 patients had complex ventricular ectopy (Class 2 to 5), of which nine patients had nonsustained VT. Group III included 10 healthy male controls 24 to 40 years of age with no clinical evidence of organic heart disease or arrhythmias.

There were no significant differences between Groups I and II with regard to age, infarct location, presence of left ventricular aneurysms, or QRS duration. Left ventricular ejection fraction was significantly less in patients with infarction who had manifested sustained VT or VF compared with ejection fraction in Group II patients (34%.+-.16 vs. 45%.+-.15, p<0.02).

The FFT analysis of FIG. 5 of signal averaged X, Y, and Z ECG signals showed significant differences in the mean 60 dB area and the mean 40 Hz intercept of the terminal 40 msec of the QRS and of the ST segment in patients with prior myocardial infarction and a subsequent episode of sustained VT or VF compared with values in patients with prior myocardial infarction without these arrhythmias and with values in normal subjects. There were no significant differences in the 60 dB area or 40 Hz intercept of the terminal QRS or ST segment in patients with myocardial infarction without sustained VT compared with normal subjects.

Representative plots of FFT analysis of the terminal QRS complex from a patient with prior myocardial infarction without sustained VT and from a patient with prior myocardial infarction with sustained VT are shown in FIGS. 6A-C and 6D-F, respectively. Each depicts power vs frequency plots of the terminal 40 msec of signal averaged QRS complexes recorded from bipolar X, Y, and Z leads along with values for the 60 dB area and the dB drop at the 40 Hz intercept. In each lead, the terminal 40 msec of the QRS complex from the patient who had manifest sustained VT contained relatively more high frequency components than the complex from the patient who had not, reflected by a greater value for the 60 dB area and a lesser dB drop at the 40 Hz intercept. Similar plots were obtained for the FET analysis of the ST segments from the same two patients. In each lead, the ST segment in the signal from the patient who had manifest an episode of sustained VT contained relatively more high frequency components than the ST segment from the patient without VT. Spectral differences in the terminal QRS and ST segment were consistently most marked at frequencies less than 120 Hz.

Based on results of the FFT analysis of FIG. 5 of the terminal 40 msec of the QRS complex in normal subjects (Group III), mean 60 dB area values greater than 2400 and mean 40 Hz intercept values less than 47 dB were defined as abnormal and indicative of an increase in high frequency components in the terminal QRS. Abnormal values for both the 60 dB area and 40 Hz intercept were found in 88% of patients with prior myocardial infarction having a subsequent episode of sustained VT (Group I) and 15% of patients with prior myocardial infarction without sustained VT (Group II).

Based on results of the FFT analysis of FIG. 5 of the ST segment in Group III controls, mean 60 dB values greater than 2500 and mean 40 Hz intercept values less than 52 dB were defined as abnormal and indicative of increased high frequency components in the ST segment. Abnormal values for the 60 dB area of the ST segment were found in 81% and 25% of Group I and Group II patients, respectively. Abnormal values for the 40 Hz intercept were found in 76% and 20% respectively.

Values for both the 60 dB area and 40 Hz intercept of the terminal QRS and ST segment were independent of QRS duration, left ventricular ejection fraction, and complexity of spontaneous ventricular ecopty.

An alternate embodiment of the above invention is now described in connection with FIGS. 8-14. The combined terminal 40 millisecond QRS and ST segment of each signal averaged X, Y and Z lead is identified with the use of the display cursor and standard electrocardiograph criteria 802 and 804. See also FIG. 9 which depicts within cursor lines the combined terminal QRS and ST segment of interest. In a manner similar to FIG. 5, the above region of interest is multiplied by a four-term Blackman-Harris window 806. Next, each of the signal averaged signals is scaled by identifying the maximum magnitude of the averaged signal and setting it to unity 808. Then a 512 point fast-Fourier transform is calculated 810 in a manner as described before in connection with FIG. 5 only now the FFT is performed on the combined terminal 40 millisecond QRS and ST segment. The magnitude of the Fourier transform is then squared 821 to obtain the energy spectrum of the signal and the result is plotted 814.

A representative plot of an energy spectrum is shown in FIG. 10. To detect smaller peaks which might be obscured by the dominant amplitudes of low frequency components, a second plot (the broken curve in FIG. 10) was generated by dividing the amplitude scale by 500 (see 816). Data was again plotted 818 but data exceeding values in the reduced scale were not plotted. The data was plotted on a high resolution plotter (Versatec, Inc.) and transferred to disc storage.

For each of the spectral plots generated (one for each signal averaged X, Y and Z signal for each patient) the data is first analyzed to locate peaks between 20 and 50 Hz 820. Peaks for the digital data could be defined in several different ways but in the preferred embodiment, a peak is an increase in magnitude for at least two adjacent data points followed by a decrease in magnitude for at least one point. The frequency range of 20 to 50 Hz was chosen after analysis over the bandwidth had demonstrated that frequencies above 70 Hz did not contribute substantially to the terminal QRS and ST segments in any group. Because of potential 60 Hz interference, frequencies between 50 to 70 Hz are not analyzed.

The magnitude of each peak frequency measured on the reduced scale (spectral plot of 818) is divided by the maximum magnitude of the entire signal measured on the initial scale (spectral plot 814) and then multiplied by 10.sup.5 to form the magnitude ratio 822. The area under the magnified curve (spectral plot 818) between 20 to 50 Hz is divided by the area under the initial curve (spectral plot 814) from 0 to 20 Hz and then multiplied by 10.sup.5 to form the area ratio 822. The area ratio is computed to determine the relative contribution of components at frequencies between 20 and 50 Hz to frequencies between 0 and 20 Hz.

For patient-to-patient comparisons, the X, Y and Z values for peak frequencies are averaged together and expressed as a single number, the mean of X, Y and Z values. The X, Y and Z values for the pre-multiplied magnitude and area ratios are averaged after log transformation and the mean value for both the magnitude and area ratios expressed as antilogs are then multiplied by a constant (1.times.10.sup.5) to facilitate graphic display 824. Program No. 4 implementing the above description of FIG. 8 is provided on pages 35-40.

Using the above described analysis of the energy spectra of the signal averaged X, Y and Z signals, three Groups of patients were studied.

Group I comprised 23 patients, each of whom had sustained prior myocardial infarction and at least one documented episode of sustained ventricular tachycardia or cardiac arrest that was not associated with a new infarct. Group II consisted of 53 patients, each of whom had sustained prior myocardial infarction without sustained ventricular tachycardia (>30 seconds in duration or associated with immediate hemodynamic decompensation), syncope, or cardia arrest. Group III comprised 11 normal subjects.

There were no significant differences in pertinent clinical features between Group I and II with respect to age, locus of infarct, or the presence or absence of left ventricular aneurysm. QRS duration was significantly greater in patients in Group I compared with values in those in Group II (106.+-.23 msec vs 90.+-.15 msec; p<0.01). Left ventricular ejection fraction was significantly less in patients in group I compared with those in Group II (35.+-.14% vs 45.+-.15%; p<0.01).

The above analysis of energy spectra of signal averaged X, Y, and Z electrocardiographic recordings showed significant differences in the area ratios and magnitude ratios of peak frequencies of the combined terminal 40 msec of the QRS and ST segments in patients with prior infarction associated with subsequent sustained ventricular tachycardia (Group I) compared with values in patients without sustained ventricular tachycardia (Groups II and III). There were no significant differences in the area ratios in recordings from patients with myocardial infarction without sustained ventricular tachycardia compared with values in normal subjects.

Representative plots of the type described above of squared fast-Fourier transformed data of the terminal QRS and ST segments from a patient with prior myocardial infarction without sustained ventricular tachycardia and from a patient with prior myocardial infarction with sustained ventricular tachycardia are shown in FIGS. 11A-11C and 11D-11F, respectively. Each panel depicts magnitude vs. frequency plots of the combined terminal 40 msec of the QRS complex and ST segments of signal averaged electrocardiographic complexes recorded from bipolar X, Y, and Z leads along with values from the area ratios, peak frequencies, and magnitude ratios. In each lead, the terminal QRS and ST segment from the patient who had manifest sustained ventricular tachycardia contained relatively more high frequency components than the complex from the patient without sustained ventricular tachycardia. The differences in frequency content were more marked between 20 to 50 Hz. The terminal QRS and ST segments from the patient who had no manifested sustained ventricular tachycardia did contain components with frequencies above 20 Hz. However, the overall contribution of these components to the entire signal was modest as reflected by the low area and magnitude ratio values.

FIGS. 12A-12C and 12D-12F illustrates another example of energy spectra of the terminal QRS and ST segments from patients without and with sustained ventricular tachycardia, respectively. The terminal QRS and ST segments from both patients contained components with frequencies between 20 to 50 Hz but differed markedly with respect to the relative contributions of these components to the entire signal. In the X and Z leads, the terminal QRS and ST segments from the patient who had manifest sustained ventricular tachycardia contained a 10 to 100-fold greater proportion of components in the 20 to 50 Hz range compared with corresponding electrocardiographic segments from the patient without sustained ventricular tachycardia.

Comparisons between values for the area ratios for the three patient groups are shown in FIG. 13. There were significant group differences in area ratio values between patients with prior myocardial infarction who had manifest sustained ventricular tachycardia compared with patients with prior myocardial infarction without sustained ventricular tachycardia and with normal subjects. A 10-fold difference was evident for patients with compared to those without sustained ventricular tachycardia. There was no overlap between values among patients who had manifest sustained ventricular tachycardia and values from normal subjects. However, twelve patients with prior myocardial infarction without clinically documented sustained ventricular tachycardia had area ratios overlapping values from patients who had manifest sustained ventricular tachycardia. It is not yet clear whether these 12 patients are at increased risk for development of sustained ventricular tachycardia.

FIG. 14 illustrates the mean peak frequencies detected between 20 to 50 Hz and the corresponding magnitude ratios for the three patient groups. There were no significant differences in the peak frequencies among patients in the three groups (28.+-.4 Hz and 41.+-.4 Hz, in Group I; 30.+-.3 Hz and 43.+-.3 Hz, Group II; and 28.+-.5 Hz and 43.+-.3 Hz, Group III). However, the relative contribution of the magnitudes of these peak frequencies to the overall magnitude of the spectral plot of their terminal QRS and ST segments differed significantly. Thus, the terminal QRS and ST segments in patients with prior myocardial infarction who had manifest sustained ventricular tachycardia contained a 10 to 100-fold greater contribution from components in the 20 to 50 Hz range compared with corresponding electrocardiographic segments in patients without sustained ventricular tachycardia. No frequencies above 50 Hz contributed substantially to those electrocardiographic segments in any group. ##SPC1##