An Engineering Perspective of External Cardiac Loop Recorder: A … · 2016-11-21 · ReviewArticle An Engineering Perspective of External Cardiac Loop Recorder: A Systematic Review

Review ArticleAn Engineering Perspective of External Cardiac Loop RecorderA Systematic Review

Avvaru Srinivasulu1 and N Sriraam2

1Department of Electronics and Instrumentation Engineering GITAM University Bangalore Campus Bangalore India2Center for Medical Electronics and Computing MS Ramaiah Institute of Technology Bangalore India

Correspondence should be addressed to N Sriraam sriraammsritedu

Received 29 June 2016 Accepted 28 September 2016

Academic Editor Sotirios Korossis

Copyright copy 2016 A Srinivasulu and N Sriraam This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

External cardiac loop recorder (ELR) is a kind of ECG monitoring system that records cardiac activities of a subject continuouslyfor a long time When the heart palpitations are not the frequent and nonspecific character it is difficult to diagnose the diseaseIn such a case ELR is used for long-term monitoring of heart signal of the patient But the cost of ELR is very high Therefore it isnot prominently available in developing countries like India Since the design of ELR includes the ECG electrodes instrumentationamplifier analog to digital converter and signal processing unit a comparative review of each part of the ELR is presented in thispaper in order to design a cost effective low power and compact kind of ELRThis reviewwill also give different choices available forselecting and designing each part of the ELR system Finally the review will suggest the better choice for designing a cost effectiveexternal cardiac loop recorder that helps to make it available even for rural people in India

1 Introduction

Norman J Holter (1914ndash1983) the famous American bio-physicist introduced a remote cardiac telemetry first time inthe 1940s [1]TheHolter systemwas developed for homeECGmonitoring of patients with suspected cardiac arrhythmiasThe originalHoltermonitor had analog patient interface elec-tronics a 75 lb backpack with a reel-to-reel FM tape recorderand large batteries It was the first monitoring system thatcould record single ECG lead 24ndash48 hours [2] and analyseambulatory ECG data outside a standard hospital or outpa-tient care setting At present theHoltermonitors are availablein the market with the cost of about $369ndash$2490 [3] depend-ing on their features and the cost of Holter test is around$175ndash$250 [4] if it is interpreted by a cardiologistThe clinicalneed to monitor ambulatory ECG has resulted in advancesin technology that now allow us to monitor heart rhythmsremotely through a wide variety of devices including ambu-latory external monitors and implantable event recorders

Implantableinsertable loop recorder (ILR) was devel-oped first time by Medtronicrsquos Reveal [5] (the worldrsquos first

implantable diagnostic device)The Reveal ILR detects ECGsduring the actual episode which may allow physicians totake decisions or confirm an abnormal heart rhythm moredefinitively Because it could be worn continuously for 14months the likelihood of capturing heart rhythm during aninfrequent episodewas probableThe cost per diagnosis usingILR is around $6158 [6] The cause of seizure-like symptomsor related symptoms was diagnosed with the Reveal ILR thatmay also result in fewer physician and emergency room visitsand reduce the number of tests involved when trying todiagnose their cause Most importantly diagnosing the causehelps in early treatment effectively Even though ILR wasuseful in monitoring of ECG for the detection of abnormalepisodes it had some disadvantages that include the follow-ing (1) a minor surgical procedure is needed (2) there isalways difficulty in differentiating supraventricular from ven-tricular arrhythmias (3) under- or oversensing may exhaustthe memory of the ILR and (4) cost of the device is more

To overcome the limitations of both the Holter andILR an intermittent patient- or event-activated recorder was

Hindawi Publishing CorporationJournal of Medical EngineeringVolume 2016 Article ID 6931347 16 pageshttpdxdoiorg10115520166931347

2 Journal of Medical Engineering

Table 1 Comparison among Holter monitor ELR and ILR

Advantages Limitations Indications Diagnostic yield

Holter monitor Low cost continuousmonitoring

Short duration ofmonitoring with lowdiagnostic yield

Patients with very frequentsymptoms (ge1 week) 6ndash22

External looprecorder

Retrospective andprospective ECG recordspossibility to recordasymptomatic arrhythmiasautomatically

Poor recordings poorpatient compliance towearing device continuousdevice maintenancerequired

Compliant patients withintersymptom interval le 4weeks

24ndash47

Implantableloop recorder

Prolonged monitoringwithout external electrodeshighest diagnostic yield

Invasive implantation withrisk of local complicationshigh cost

Early phase of evaluation ofpatients with recurrentsyncope of uncertain originthat have absence of highrisk criteria that requireimmediate hospitalizationor intensive evaluation anda likely recurrence withindevice battery longevity

43ndash78

ECG electrodes IA Filtering AD

Signal processing unit

PClaptopmobile

Accelerometer gyroscope

Figure 1 Block diagram of external cardiac loop recorder

developedThis is also referred to as eventmonitor or externalloop recorder (ELR) The ELR is smaller than Holter in sizeand is attached to the patient through chest electrodes andrecords the data when it is activated by the patient or by anautomatic trigger that detects irregular heart rates It is usedfor monitoring up to 14ndash30 days The cost of ELR is $627and cost per diagnosis using ELR is around $2659 [7] Theuse of ELR avoids the surgical implantation of electrodesBut the activation of the device every time by the patientis difficult unless the autotrigger is used The autotriggeractivates the device as it is programmed which is built intothe monitor Therefore during infrequent symptoms thereis a more chance of missing the activation of the deviceThismay not give enough information for effective diagnosisAfter recording using any of the above-mentioned systemsthe data is sent to the central monitoring station where thedata is loaded in the computer and analysed Finally thereports are sent to the doctor for a final decision or for furthertests to detect and confirm the disease As mentioned aboveELR is providing the noninvasive diagnosis by long-termmonitoring Even the cost of design is less the ELR test cost ishigh Further the recorded data has to be sent to the specialistto analyse the data which increase the cost further And thereis no option for autosending the recorded data or analysed

data to the doctor The comparison among Holter ILR andELR is given [8] in Table 1

In Table 2 some of the available ILR and ELR products aregiven [5 9ndash16]

The mentioned products in Table 2 are very expensiveand most of them are not significantly available in IndiaDistributors are there all over India but they are providingonly a few products like Medtronic SpiderView SEEQ MCTPiix NUVANT MCT GE Healthcare MARS SEER 1000SEER Light Omron HCG801 and BPL cardiac loop recordermonitor Therefore a systematic review on internal parts ofECG monitoring system is required to design a cost effec-tive ambulatory ECG monitoring system with an accuratemeasurement portable and wearable one as explained in thefollowing sections

2 Designing of External CardiacLoop Recorder

The design of external cardiac loop recorder consists of ECGelectrodes instrumentation amplifier filtering analog to dig-ital converter and signal processing unit PClaptopmobileis also used to analyse the data The major blocks andconnection of them are shown in Figure 1

Journal of Medical Engineering 3

Table 2 ILR amp ELR products available

Devicecompany Mode Expected monitoring duration Max continuous recordingperiod

Reveal Plus 9526Medtronic Implantable 14 months mdashReveal DXMedtronic Implantable 3 years 42minReveal XTMedtronic Implantable 3 years 42minReveal LINQMedtronic Implantable 3 years mdashSleuthTransoma Implantable 28 months 630minConfirm DM2100St Jude Implantable 3 years 48min (147 episodes)Confirm DM 2102St Jude Implantable 3 years 48min (147 episodes)MCOTCardioNet External Few weeks 21-day continuous monitoringLifeStar ACTLifeWatch External Few weeks 21-day retrievable monitoringLifeStarLifeWatch External Few weeks 10mineVolutioneCardio External Few weeks 30min3300 BTVitaphone External Few weeks 20minV-PATCHMedical System External Few weeks 30 hKing of the HeartInstrumedics External Few weeks 6minSpiderFlashSorin External Few weeks Several hoursCardiocallReynolds Esaote External Few weeks 18minSuperI-Cardia External Depends on patient compliance 2 recordingsCardio PALMedicomp External Depends on patient compliance mdashSEEQMCTMedtronics External 30 days mdashPiix NUVANTMCTCorventis External 7 days mdash

HCG801Omron External 30 seconds can be made whensymptoms occur

30 sec window indication125MB memory required

SEER 1000GE Healthcare External 24 h or 48 h or 3 days (threemodes are available) Nonremovable digital memory

SEER LightGE Healthcare External 24 h (48 h for SEER Light extent) 32MB memory required

The ECG signal is acquired from the chest electrodes andis amplified by the instrumentation amplifier The amplifiedsignal is filtered by the suitable filter to remove the noiseMostly band pass filter is used for noise removal Later ananalog to digital converter converts the filtered signal intoa digital form which is suitable to process signal by theprocessor A signal processing unit is used for processingand feature extraction of the signal to find the normal andabnormal conditions of the patient For the effective detectionof the abnormal conditions during daily activities accelerom-eter andor gyroscope is also used along with the chestelectrodes By correlating the signals from chest electrodesand accelerometergyroscope the abnormality of the patientcan be defined The signal processing unit is connected tothe PClaptopmobile or system on chip (SoC) where theopen source software is installed and used for displayingprocessing and saving the data Further communicationwith the doctor can be provided using wireless technologywhich helps to develop the smart city The comparative studyof each block is explained in following sections

21 ECG Electrodes Basically disposal electrodes that maybe AgAgCl gel type wet sensors or dry sensors are used foracquiring biopotentials from heart The gel type disposable

Figure 2 Disposal AgAgCl electrodes

electrodes have a circular contact The close electrode place-ment is allowed by small vinyl backing where necessary anda slightly less firm adhesive allows ouchless removal Theelectrodes incorporate liquid electrolyte gel and moderatelyhigh chloride salt concentration for quick and accuratereadings These disposable electrodes shown in Figure 2provide the same signal transmission as reusable electrodeswith added convenience Each peel and stick electrode is


36 months 24 months 24 months

AQUA-TAC AQUA-WET AQUA-SET

Figure 3 SKINTACT electrodes

Figure 4 Dry electrode

pregelled anddesigned for one use only It is very cost effectivecompared to other electrodes It is easily attachable to thesubject himselfherself and there will not be any assistanceneeded The placement of electrodes is also simple and onlythree electrodes at a time are required for two lead ECGacquisition systems as one electrode is the reference Theseelectrodes can be used for longer periods depending on thecomfort level of the subject

SKINTACT electrodes [73] shown in Figure 3 are avail-able in the market with three different gels AQUA-TACelectrode with solid adhesive gel provides 100 contact withskin surface AQUA-WET electrode with liquid gel providesfast pickup of ECG signal which is preferred for short termmonitoring and AQUA-SET electrode with solid wet gel isused for long-term monitoring

North Carolina State University researchers [74] haddeveloped a new dry sensor shown in Figure 4 for long-term ECG and EMG monitoring This device has relied onelastic conductors made from silver nanowires embedded ina pliable polymer

Imec and Holst Centre introduced the polymer dryelectrodes [75] shown in Figure 5 fabricated from ethylenepropylene diene monomer (EPDM) rubber which offers ahigh user comfort and high conductivity

PDMS (polydimethylsiloxane) based surface electrodeshown in Figure 6 was designed [76] for the long-termand unsupervised monitoring This electrode did not shownegative influence on skin even it was worn for one week

Apart from wet and dry electrodes there are noncontactelectrodes called capacitive electrodes These were fabricated

Figure 5 Polymer dry electrodes

Au + Ti layer

Wire connection

Copper wire

Velcro

PDMS substrate

Figure 6 PDMS surface electrode

on silicon with a thermally grown silicon dioxide as thedielectric layer Dry capacitive electrodes were used forshort-term ECG monitoring [77] A new class of bioelectricsensors was developed by quantum applied science andresearch (QUASAR) in 2002 These electrodes were capac-itively coupled with the body by incorporating the sensorsinto shirts elastic belts and glasses The QUASAR two-generation electrodes are shown in Figure 7(a) The first-generation electrode IBEv1 is a larger square sensor (110158401015840 times 110158401015840)used to measure bioelectric potentials through T-shirt [78]The second-generation electrode IBEv2 was developed as asmall circular shape sensor shown in Figure 7(b)


(a) (b)

Figure 7 (a) QUASAR IBEv1 electrodes (b) QUASAR IBEv2 electrodes

22 Accelerometers and Gyroscopes Accelerometers andgyroscopes are also used along with dry or wet sensorsfor cancelling muscle contraction interferences to measureheart rate under different activities like stress movementsand so forth The accelerometer is a 3-axis one It is usedin tilt-sensing applications as well as dynamic accelera-tion resulting from motion or shock to measure the staticacceleration of gravity In previous work done the peopleused the accelerometer for different purposes In previouswork done the people used the accelerometer for differentpurposes ADXL335 triaxial accelerometer [9 79] and triaxialaccelerometer MotionPodTM by MOVEA were used forremoval of motion artefacts SDI1221 a low cost integrated1-axis accelerometer was used in zero to medium frequencyinstrumentation applications to provide extremely low noise(5 120583gradicHz) [80] A triple axis accelerometer [81ndash83] andMMA7260QT [84] were used in telehealth monitoringADXL330was used in deciding of the cardiac disease [85 86]Bosch BMA180 accelerometer was used in human behaviourtracing [87] A triple axis accelerometer [81 83 88ndash90]ADXL345 [91] and ADXL330 [92] were used in activityrecognition MC301 made byWacoh was used in ambulatorymonitoring to find human posture and walking velocity [93]MMA8451Q (Austin TX USA) a triple axis low powercapacitive digital accelerometer (freescale semiconductor)[94] a triaxial accelerometer (patch sensor device designedby Vital Connect Inc (Campbell CA)) [95] and inbuilton-board 3-axis accelerometer SCA3000 [96] were used inextraction of respiratory rate And also a triaxial accelerom-eter was used to measure the body movements [90] ordaily stress [97] and for left ventricular functions monitoring[98] A triaxial gait accelerometer MMA7260Q (freescalesemiconductor Austin TX USA) [99] piezoelectric foils[100] and Pegasus activity monitors developed by ETB UKwere used for time-frequency analysis of heart rate Triax-ial accelerometer ADXL335 [9 79] and MotionPodTM byMOVEA [98]were used as the reference for removingmotionartefact by adaptive filtering algorithm (LMS or ANC) inacquiring of ECGduring treadmill exercise Apart from thesea triaxial accelerometer (LlS344ALH ST Microelectronics)was used for seismocardiography

Figure 8 3-axis accelerometer ADXL345

Among all the accelerometers mentioned in Table 3the model ADXL345 shown in Figure 8 can be selectedbecause of less power consumption and better full scalerange with 2ndash36V supply voltage In ECG monitoring theaccelerometer is used to get the change in acceleration dueto body movements during daily activities This is helpful indetecting the arrhythmias Finally the heart rate measuredby disposal electrodes and the accelerometer readings will becorrelated Using this information alerts or notifications aresent

The gyroscope is used to find the tilt in position whenthere is motion in the body This is required for monitoringof ECG during daily activities In previous work gyroscopeswere used in different applications like L3G4200D gyroscopeused for head movement tracking along with accelerometerandmagnetometer [17] Gyroscope and accelerometer inbuiltMEMS chip [101] were used in robotic arm control bydetecting the motion of arm [102] and vehicle speed control[103] Ring laser gyroscope [104] and microgyroscope [105]are advanced gyros used for various applications In cardiacapplications gyroscope was used for monitoring electricand mechanical functioning of heart [106] (gyro developedby Zimpher Technology and Shimmer Research was used


Table 3 Specifications of some accelerometer ICs available

Accelerometer IC Supply voltage Powerconsumption Full scale range Bandwidth

ADXL335 18 Vndash36V 350 120583A (typical) plusmn3 g

For the119883- and119884-axes 05Hz to

1600Hz and for the119885-axis 05Hz to

550Hz

ADXL330 20Vndash36V 200 120583A and VS =20V (typical) plusmn3 g

For119883- and 119884-axes05Hz to 1600Hzand for the 119885-axis05Hz to 550Hz

ADXL345 20Vndash36V 40 120583A at VS = 25 V(typical) plusmn16 g

SDI1221 +50 and +25 volts +5 VDC 8mApower (typical) plusmn2 g 0ndash400Hz

SCA3000 235Vndash36V 25 V 480 120583A typ plusmn2 g 45Hz (typical)LIS344ALH 24Vndash36V plusmn2 gplusmn6 g 18 kHz for all axes

MMA7260QMMA7260QT 22Vndash36V 500 120583A plusmn15 g2 g4 g6 g 350Hz for119883 amp 119884and 150Hz for 119885

MMA8451Q 195Vndash36V 6 120583A to 165 120583A plusmn2 gplusmn4 gplusmn8 g

Bosch BMA180VDD =

162Vndash36V andVDDIO =12Vndash36V

650 120583A (typical)plusmn1 g plusmn15 g plusmn2 gplusmn3 g plusmn4 g plusmn8 gplusmn16 g

02Hzndash300Hz forBPF

in [107]) means heart rate [108] rotational velocity offoot [108] emotional eating (2-axis gyro was used) humanposture and walking velocity (ENC03J developed by MurataManufacturingCo Ltd Kyoto Japanwas used in [18]) stridestrength and walking velocity (ENV05S developed byMurataManufacturing Co Ltd Kyoto Japan was used) musclecontractions (vibrating disc piezoelectric gyroscope was usedin [19]) and motion processing in handsets (InvenSenseMPU-3000 3-axis MEMS gyroscope was used)

The differences between gyroscope and accelerometer aregiven in Table 5 that help in the selection of gyroscope oraccelerometer or both for ECG monitoring systems

In order to differentiate the ECG signal due to heart activ-ity from the patientrsquos daily life activities accelerometer andgyroscope alone are not sufficientTherefore it is suggested touse both accelerometer and gyroscope to find daily activitiesof patient effectively

23 Placement of Electrodes The placement of electrodes onthe body varies based on type ofwearable design For differentwearable types placement of electrodes according to thepreviously proposed designs is given in Table 6

24 Instrumentation Amplifier (IA)

241 Mostly Used IA ICs There are a number of instrumen-tation amplifier ICs available in the market suitable for ECGsignal amplification The use of IA in IC form is very easyandmore convenient in ECG signal acquisition because of itssmall size and high noise immunity The most widely used

IA ICs were developed by Texas Instruments and AnalogDevices Texas Instruments ICs INA116 [109 110] INA121[111] and INA128 [112] were most widely used in ECG signalacquisition systems INA116 provided high input impedance(1015Ω) and the bandwidth of 038ndash44Hz (plusmn5)with a singlesupply of 2V it was used for long time ECG monitoringof athletes [109] It was also used in the designing of lownoise EEGECG sensor circuit [110] INA121 with a two-inputvoltage buffer as driving Right Leg (RL) circuit provideddifferential gain = 1000 from 005Hzndash100Hz and common-mode gain = 006 at power-line frequency (50Hz) that resultsin CMRR = 86 dB [111] Analog devices ICs AD620 [113]and AD623 [114] were used for ECG signal acquisition andmonitoring

242 Circuit Designs of IA Basically the instrumentationamplifier is designed using operational amplifier which actsas voltage amplifier [115] that provided gain = 5483 dBCMRR = 14161 dB and bandwidth = 223Hz [55] A simpleunity-gain buffer stage and differential amplifier stage withhigh input impedance [116] were used to design IA to haveoptimised low-frequency response low power and CMRRThe minimum input resistance of the amplifier required wasobtained as 13MΩ [117] A composite stabilised amplifierwith active current feedback at its input stage was used toreduce amplifier saturation problems and baseline drift [118]in off-the-shelf ECG amplifier for a continuous long durationBut the amplitude is not matched with that of standard(3 electrodes) voltage ECG amplifier If RE lt 50 kΩ the


bandwidth of the circuit will decrease below the bandwidth ofthe acceptable limit DDA (differential difference amplifier)was used to lower the power consumption and keep the openloop gain to enough value The AC coupled technique wasused to reduce offset noise DDA with AC coupled technique[61] provided power supply rejection ratio = 62 dBampCMRR=150 dB at 10Hz and with the preferred input noise at 5 120583VHzpower consumption = 399 120583W at 1Hz To remove offsetvoltage and reduce 1119891 noise the low-frequency signal wasto be eliminated This was done by differential AC couplingnetwork and the HP difference amplifier [119] A designfor remote electrocardiogram system which consists of fivestages ECG input isolated amplifier main amplifier activeBRF and high order LPF with bandwidth 1Hzndash200Hz [120]was used for ECG signal amplification and power supply(60Hz) noise reduction

Two-stage IA using operational transconductance ampli-fier (OTA) and common-mode feedback amplifier topologywas used for common-mode amplifier noise reduction Thisprovided power consumption = 147 120583W and CMRR = 82 dB[56] An IA with series combination of two OTAs (one ispreamplifier and second is variable-gain amplifier) providedpower consumption = 233 nW bandwidth = 21Hz gain =442 dB and CMRR = 80 dB [60] Flicker noise was removedby both chopper stabilised front end amplifier [121] andchopped capacitively coupled IA (CCIA) [122 123] Choppertechnique which was implemented using folded cascodestructure provided 3644 dB of SNR in [54]

The instrumentation amplifier using the opamp for ECGsignal acquisition cannot reduce noise much effectivelyTherefore in order to solve this problem ECG amplifiers weredesigned using CMOS technology [56ndash63 124ndash127] whichalso provide less power consumption and small area Thenoise reduction in terms of CMRR obtained in differentpapers is mentioned in Table 7

From Table 7 one can observe that most of the workreported was based on usage of same processing technologywith different battery voltage The work done in [62] wasgiven better common-mode rejection ratio with aMonolithicCMOS current-mode instrumentation amplifier

25 Filter Filtering was required to remove the noise in ECGsignal acquisition from electrodes followed by IA The noiseinterferences were involved inmany ways in ECG acquisitionas its amplitude is less (in the order of mV) and variabilityof ECG segments durations Muscle contractions electrodemovements during acquisition base line wandering and60Hz power supply noise were some of the significant noiseinterferences And also filtering was required to separatethe segment of interest from the acquired ECG signal likeP wave R-peak QRS complex T wave and ST segmentHere removal of noise interference was not considered in thispaper Different filters and their frequency range for differentparameters acquisition used by previously proposed authorsare given in Table 8 for selecting and deigning of requiredfilter

FromTable 8 it is shown that themost of the authors usedLPF and HPF or BPF for measuring almost any parameterBut the frequency range is not the same for all It is differentfor different parameters Therefore the designer has to selectthe frequency range based on hisher segment of interest

26 ADC The ADC ICs such as 16-bit 100-kSPS SARADC ADS83212 [33] 10-bit SAR ADC [30 38 128] and24-bit ADS1292 [129] were used for analog to digitalconversion of signal But nowadays the signal processingdevelopment boards like Texas products ADS1298 ADS1191ADS1192 ADS1194 ADS1196 ADS1198 ADS1291 ADS1299ADS1298R ADS1296R ADS1296 ADS1294R ADS1294ADS1293 and ADS1291 that provide analog voltage 27 Vndash525V and digital voltage 165V to 36V [130] and analogdevices ADAS1000 (low power 5-electrode ECG analog frontend) andAD8232 (single-lead heart ratemonitor analog frontend) [131] are available with ADC inbuilt at significantlyreduced size power and overall cost Therefore there is noneed for external ADC to place

27 Signal Processing Unit Generally microcontroller boardis used as signal processing unit to process the digi-tal signal This unit is further connected to PClaptopto display the signals and measurements It can also beused to communicate with other systems using transmit-ter and receiver In previous designs proposed for shortterm monitoring of ECG for 10 sec or 1-2 minutes MSP430microcontroller was used [34 71] and for long-term mon-itoring TI CC2530 system [37] CC2431 [132] DSP [128]DSP chip TMS320VC5509A [133] TMS320F2812 [134]TMDX5505eZDspVC5505eZdsp [33] MSP430 (monitoringfor 45 days) [68] MSP430F5515 [129] MSP430F1232 [43]MSP430FG439 [135] MSP430F2418 [136] MSP430F5529[66] (monitoring for 88 h) [39] MSP430F5419A (monitoringfor 48 h) [137] ATmega8 [41] ATmega328 [42] ArduinoUNO (ATmega328) [47] ATmega8L [28 31 32] ConcertoMCU [65] Revitive Device [27] PIC18LF4620 [69] AlteraEP2C35 Nios II soft-core CPU based FPGA [138] ARM9[139] ADuC842 [140] C8051F021 [141] 32-bit ARM CortexM0 CPU (monitoring for 24 h) [30] and STM32 chip as thesystem controller with ARMCortex-M3 core (monitoring for44 h) [67] were used

28 Communication to PCLaptopMobile Phone

281 Need of Communication to PCLaptopMobile PhoneSocNetwork After acquiring ECG signal to display process andreport the results of analysis to physician or doctor fordiagnosis of the disease there is a need for connecting to PCor Laptop Mobile also can be used with specially designedapps

282 Available Communication Techniques

(1) USB-SPI is generally used to connect the MC devel-opment board to PC To display the signals andmeasurements MATLAB Simulink GUI or speciallydesigned GUI is used


(2) Bluetooth is used for connecting to PC or mobilephone To display the signals and measurementsspecially designed GUI is used in PC and for mobilephone (and also tablet) an android app is usedMotorola cell phone is providing an app developedwith Java 2 Micro edition (J2ME)

(3) IEEE 802154ZigBee is used for PC connectionThe signals can be displayed by using LabView orMATLAB GUI

(4) WiFi is used for connecting to PC or mobile phoneWith a specially designed GUI developed in Java thesignals can be displayed on PC and mobile phoneOpen source software (the app is written in X-codeusing object C) developed by EP Ltd is available inApplersquos iPhone 4S smartphone

(5) GSMGPRSGPS is used for long distancemonitoringof ECG by connecting with PC or mobile phone

(6) Some of the system on chip (SoC) products likeAT86RF212BAT86RF233 AT86RF215 AT86RF215Mand AT86RF215IQ [142] will provide wireless com-munication network through ZigBee technologyTMS37157TRF796XTRF7970AT86RF212MCRF200ADF7021 and ADF7025 [143] will provide commu-nication using RFID technology CC1101 CC1110CC430 CC1190 CC11XL CC112X and CC120X [143]will provide communication using WPAN technol-ogy CC2520CC2530CC2530ZNPCC2531 CC2533ADF4242 andAT86RF231 [143] will provide commu-nication using ZigBee technology CC2560 CC2540CC2570 EM250 EM260 BCM4329 and BCM2045[143] will provide communication using BluetoothtechnologyWL1271WL1281 BCM43241 BCM2529BCM4318 BCM4330 BCM4752 and AR6102 [143]will provide communication using WiFi technologyAnd WL1281 NL5500 UBX-G6010 BCM4750 andSiR starV [143] will provide communication usingGPS technology

283 Selection of Effective Communication Technique Thecommunication mode is selected based on the distance ofmonitoring the signals For short distance wired connectionlike USB SPI or wireless communication (1 or up to 100mdepending on radio class) through Bluetooth or ZigBeetechnology (up to 75m) or WiFi (indoors about 150 feet(46m) and outdoors about 300 feet (92m)) is generallypreferred For long distances GSMGPRS (35 kilometres)or GPS (up to 25000Km) is preferable At present all thecommunication technologies are inbuilt in the hardware andavailable as SoC (some of available SoC products are given inSection 282)When the SoC is selected for signal processingit is better to select the suitable SoC product which is havingpreferred communication network technology By providinglong distance communicationwith the doctor there is a scopefor online monitoring of the patient condition and onlinediagnosisThis will not only save money and time it will save

lives of poor people And also it helps to develop a smart cityin the area of medical engineering

3 Discussion

The death rate is increasing every year due to heart diseasesfrom past few decades in India This can be reduced by earlydetection of symptoms of abnormalities A few years back theECG systems for detecting abnormalities were only availablein the hospital and used only in the presence of specialistsIt was very difficult to go every time to the hospital and takethe ECG which was also very expensive especially for ruralpeople But present situation is slowly changing by using thehealth monitoring systems Therefore everything is going tochange within few years in India like developed countries inthe field of biomedicine by developing the smart andwearablehealthmonitoring systems Somuch of work is done bymanypeople but there is a lack of validation and communicationprovision with the doctor There are options for recordingand sending the data to the service centre where the data isanalysed But there is no accessibility of data to the user orpatient And also they used commercial software which islicensed and very costly Therefore the net cost is very high

In order to overcome these limitations and to add themissing features in existing systems a new framework is pro-posed in this paper In this review quantitative informationfor designing of external cardiac loop recorder (ELR) is pre-sented as a study of real-time ECG monitoring from remotearea continuously With the proper selection of the devicessuch as electrodessensors instrumentation amplifier filtersprocessor and communication mode an advanced externalcardiac loop recorder is going to be designed to achievebetter performance with less cost New framework includesan option for saving the recorded ASCII data in text or excelform and then it is easy to access and process the dataFurther the data can be processed and extract the featuresfor detecting the normal or abnormal condition of the patientby using open source software called Scilab that reduces thecost of the system by avoiding commercial software usedfor analysis And also by using open source software likeTeraTerm CoolTerm and Processing with Arduino data canbe sent to a doctor via Bluetooth or Wi-Fi Using Gobetwinoopen source software with Arduino data can be sent via theinternet Therefore the doctor can receive and analyse thedata using open source software and further he can send thesuggestions or precautions to the patient at an early stage Ifsuch a system is designed it would become amilestone in thefield of biomedical engineering andwould help to develop thesmart city towards the biomedical field in India And also itwill reach the rural people effectively so that the death ratedue to heart diseases can be reduced

It is evident from Tables 1ndash9 that one can design andconfigure appropriate internal circuitry components for thedevelopment of the cost effective external cardiac looprecorder system The appropriate selection of open sourcesoftware along with suitable internal circuitry will giveway for new ELR suitable for implementation with lesscost Under a pilot process a working prototype is underinvestigation by duly considering all the design parameters


Table 4 Specifications of some gyro ICs

Ref number Gyro ICsensor Operating voltage Axes

[17] L3G4200D 26Vndash55 V plusmn250 (119883) plusmn500 (119884)plusmn2000∘s (119885)

[18] ENC03J 27 Vndash55 V Max plusmn300∘s[19] ENV05S 8ndash135 V Max plusmn90∘s

[20] Integrated Dual-Axis Gyro-IDG-300 3Vndash35 V Full scale range ofplusmn500∘sec

[21] Integrated Dual-Axis Gyro-IDG-500 27 Vndash33 V Full scale range ofplusmn500∘sec

[22] Single Chip Rate Gyro EVAL-ADXRS610 475Vndash525V (typical 5 V) plusmn300∘sec yaw rate

[23] SCC2000 Series Combined Gyro Sensor and Accelerometer 3Vndash36V 119883- or 119885-axis plusmn125∘s orplusmn300∘s

[24] XV-3500CBXV3900CB 33V plusmn100∘s[24] XV-3510CB 33 V plusmn300∘s[24] XV-3700CB 33 V plusmn300∘s to plusmn1500∘s[24] XV7011BBXV7001BB 27V to 36V plusmn100∘s[24] AH-6120LR 3V plusmn1000∘s[24] AP-6110LR 285V to 36V plusmn300∘s

Table 5 Differences between gyroscope and accelerometer

S number Gyroscope Accelerometer

1 It determines orientation It measures static (eg gravity) as well as dynamic (egsudden startsstops) acceleration

2 Senses rotation Cannot sense rotation

3It measures the rotation rate arounda particular axis based onangular momentum

It measures linear acceleration based on vibration

4 A gyroscope is used to determine angular position Two-axis accelerometer is used to determine the directionof gravity

5

Applications in navigation on unmanned aerial vehiclescompasses and large boats ultimately assisting withstability in navigation and altitude indicator on typicalaircraft

Applications determines screen orientation and acts as acompass undoing actions by simply shaking thesmartphone

6 Gyroscopes are used in extra earth navigation (spacecraft)where the planet earthrsquos pull and influence disappear

3-axis accelerometer could identify the orientation of anobject relative to the Earthrsquos surface

Table 6 Electrode placement for different type of wearable

Ref paper Wearable type Number of electrodes Type of electrodes Placement of electrodes[25] Tight fitted sleeveless top mdash Dry AgAgCl electrode Chest line

[26] Wearable(vital jacket system) mdash mdash On chest

[27] BioShirt 33M AgAgCl 2223 monitoringelectrode which has foam tape

and sticky gel

ECG limb leads and augmentedunipolar limb leads

[28] Belt type 2 ECG RA-LA 11 cm apart through midline onchest

[29] Wearable belt 4 ECG

Channel 1 (+) in the fifth intercostalspace in anterior axillary line Channel1 (minus) manubrium of sternum on the

right sideChannel 2 (+) on sternum on the samealtitude as the fourth intercostal spaceChannel 2 (minus) left subclavian areaGround in the fifth intercostal space

in midaxillary line


Table 6 Continued

Ref paper Wearable type Number of electrodes Type of electrodes Placement of electrodes[30] Wearable chest harness mdash Coin sized dry-contact electrodes On chest[31] Wearable chest belt 2 ECG On chest[32] Chest belt 2 On chest

[33] Wearable ECG vest 3 Ag-AgCl Three Velcro tapes in neck back andwaist

[34] Wearable 3 AgAgCl LA RA RF

[35] Wearable 3 RA-LA 5 cm through midline andLL-LA end to center of LL 6 cm down

[36] Wearable 3 Einthoven triangle

[37] 3 ECG

RA-RL-LA placed bw midline ampdistance RA-LA is 5 cm LL is 5 cmdown from RA-LA line and 5 cm left

from midline

[38] mdash mdash mdash Sensors on the lumbar supportcushion of the seat

[39] mdash 10 mdash Standard positions to generate 12 leads[40] mdash 3 mdash Einthoven triangle[41] mdash 3 ECG RA-LA-RL[42] mdash mdash Dry clamp electrodes Located on the wrists

[43] mdash 2 Capacitive coupling electrodes On chestlead I

[44] mdash 12 mdash 12-lead ECG system

[45] mdash mdash QUASARrsquos capacitive bioelectrodes(can measure with clothes)

Integrated into a pad system that isplaced over a chair

[46] mdash 12 mdash 12-lead standard placement[47] mdash 3 mdash Einthoven triangle[48] mdash mdash Patch-type electrode On chest[49] mdash 12 mdash 12-lead standard placement

[50] mdash mdash Wet gel AgAgCl electrodes (AmbuBlue Sensor R) Below the left pectoral muscle

[51] mdash 3 mdash (RA LA RL) lead II

[52] Not wearable 3 mdashLA RA LF (separated by 10 cm) andan extra electrode placed on RL (forms

an equilateral triangle)[53] Not wearable 4 mdash RA LA LL RL

Table 7 CMRR comparison of different works done for ECGamplifier using CMOS technology

Reference paper CMRR Process tech Battery voltage[54] 71 dB 018120583m 18V dual[55] 14161 dB 018 120583m 18V dual[56] 82 dB 018120583m mdash[57] gt125 dB 018120583m 04V[58] 62 dB mdash 33V[59] gt100 dB mdash 33V[60] 80 dB 013120583m 07V[61] 150 dB 018120583m 18V[62] 16787 dB mdash mdash[63] 125 dB 018120583m mdash

and software requirements This expected design system willensure the required diagnostic precision suitable for detectingthe cardiac episodes

4 Conclusion

This research study provided an insight into the systematicreview on external cardiac loop recorders It gives the quan-titative information which helps in the selection of internalparts of the external cardiac loop recorder Although severaltechniques for monitoring cardiac episodes were availablethe scope for a new cardiac device is still in demand This isdue to the fact that the real-time cardiac episodes monitoringand its corresponding alert mechanism can help in saving thelife of the patient Suchmechanism through the advent of cost


Table 8 Filters and their frequency range for various ECG parameters

Ref number Parameters acquired Filter used Freq range[64] Heart rate Bandpass filter mdash[30] Heart rate Passive RC high pass filter 1Hz

[31] Heart rate LPF after IA notch HPF LPF 119865lpf = 150Hz 119865119899 = 60Hz119865hpf = 05Hz 119865lpf = 35Hz

[65] Heart rate LPF 119865lpf = 40ndash80Hz[45] Heart rate 8-pole Bessel bandpass filter 01ndash100Hz[37] QRS complexes heart rate BPF

[28] R-peak heart rate HPF 2nd-order Butterworth filter (two 1st-order LPF) 119865ℎ = 005Hz119865119871 = 35Hz

[32] R-peak abnormal heart beat LPF moving average filter 119865lpf = 35Hz[66] ECG and heart rate Notch filter formed by ordinary amplifier TL062 119865119888 = 50Hz[38] ECG wave R-peak LPF BPF 119865bpf = 5ndash20Hz[67] R-peaks LPF HPF[44] R-peak Adaptive filter[68] Pk-Pk Analog active RC filter a second-order Butterworth[29] HRV LPF[42] ECG PPG BP HPF LPF 119865ℎ = 016Hz 119865119897 = 103Hz[69] QRS complex Antialiasing 1-pole LPF 119865119897 = 35Hz[70] QRS T wave HPF sixth-order Bessel LPF 119865lpf = 150Hz[50] QRS complexes and T waves RC high pass filters 1198653-dB = 016Hz[71] PQRST wave Bandpass filter 0159ndash159Hz[72] Points (P Q R S T) BPF notch filter 119865bpf = 005Hz to 150Hz 119865119899 = 6Hz

[51]QRS duration RR interval HBR

R amplitude RT-intervalPR-interval QT-interval features

LPF HPF LPF119865lpf = 003Hz119865hpf = 80Hz

119865lpf = 58Hz and 19Hz

Table 9 Different microcontrollers used for ECG monitoring

MP or MC used Supply voltage range Max power consumption Memory storageMSP430 25 V to 55 V 330 120583A at 1MHz 3V 2 k byte ROM 128-byte RAMMSP430F5529 18 V to 36V 290 120583A at 8MHz 30 V 128KB flash amp 8 times 2KB SRAMMSP430F5419A 18V to 36V 230 120583A at 8MHz 30 V 128KB flash amp 16KB SRAMMSP430F5515 18 V to 36V 290 120583A at 8MHz 30 V 64KB flash amp 4 times 2KB SRAMMSP430 (F2) 18 V to 36V 220120583A at 1MHz 22 V 1KB + 256 B flash memory 128 B RAMMSP430F1232 18 Vndash36V 200 120583A at 1MHz 22 V 8KB + 256 B flash memory 256 B RAMMSP430FG439 18 V to 36V 300 120583A at 1MHz 22 V 60KB + 256 B flash memory 2 KB RAMMSP430F2418 18 V to 36V 365 120583A at 1MHz 22 V 116KB + 256 B flash memory 8 KB RAMTI CC2530 2Vndash36V 29mA at 24GHz 32KB flash amp 8KB RAMTI CC2431 2Vndash36V 27mA at 32MHz 128KB flash amp 8KB RAM

TMS320VC5509A 27-Vndash36-V mdash 128K times 16-bit on-chip RAM 64K bytes one waitstate on-chip ROM 16MB DRAM

TMS320F2812 18 Vndash33 V 19-V Core at 150MHz 128K times 16 flash 128K times 16 ROMTMDX5505eZDspVC5505eZdsp 18 V 25 V 28 V 33 V mdash 320KB of on-chip RAM 128KB of on-chip ROM

ATmega8 45 Vndash55 V 36mA at 4MHz 3V 25∘C 8KB flash 512 B EEPROM 1 KB SRAMATmega8L 27 Vndash55 V 36mA at 4MHz 3V 25∘C 8KB flash 512 B EEPROM 1 KB SRAMATmega328 18ndash55 V 02mA at 1MHz 18 V 25∘C 32KB of flash 1 K byte EEPROM 2KB of SRAMArduino(ATmega328) 5V mdash 32KB of flash 1 K byte EEPROM 2KB of SRAM

Concerto MCU(MB95F108AHS) 5V mdash 60KB dual-flash 2 KB RAM

PIC18LF4620 20V to 55 V mdash 64KB flash 3968 SRAM 1024 EEROMADuC842 mdash 45mA at 3V (core CLK = 2098MHz) 64KB flash 2 KB SRAMC8051F021 27 Vndash36V mdash 425KB RAM 64KB ROM32-bit ARM cortexM0 CPU mdash 643 120583WMHz mdash


effecting wearable external cardiac loop recorder will providea major healthcare revolution in the developing countries

Competing Interests

The authors declare that they have no competing interests

References

[1] P Zimetbaum and A Goldman ldquoAmbulatory arrhythmia mon-itoringrdquo American Heart Association Circulation vol 122 pp1629ndash1636 2010

[2] httpwwwheartorgHEARTORGConditionsHeartAttackSymptomsDiagnosisofHeartAttackHolter-Monitor UCM446437 ArticlejspV o8kk-LXnM

[3] httpstuccucomsHolter+Monitor-MbSLsTI-Buy-Exclusive-Deals-70-OFF-Save-Big-Lowest-Price-on-Holter-Monitor

[4] httpwwwmedhelporgpostsHeart-RhythmCost-for-holtor-monitorshow1630319

[5] httpwwwpmedtroniccomNewsroomLinkedItemDetailsdoitemId=116004129560020amp20format=pdf20amplang=en IN

[6] A D Krahn G J Klein R Yee J S Hoch and A CSkanes ldquoCost implications of testing strategy in patients withsyncope randomized assessment of syncope trialrdquo Journal of theAmerican College of Cardiology vol 42 no 3 pp 495ndash501 2003

[7] httpwwwispororgScientificPresentationsDatabasePresen-tation54447

[8] R Subbiah P-L Chia L J Gula et al ldquoCardiac monitoring inpatients with syncope making that elusive diagnosisrdquo CurrentCardiology Reviews vol 9 no 4 pp 299ndash307 2013

[9] C Nachane D Subramanian J Warrier and V Sinha ldquoDevel-opment of acquisition of ECG during treadmill exerciserdquoInternational Journal of Scientific amp Engineering Research vol6 no 4 pp 1285ndash1288 2015

[10] M Brignole P Vardas E Hoffman et al ldquoIndications for theuse of diagnostic implantable and external ECG loop recordersrdquoEuropace vol 11 no 5 pp 671ndash687 2009

[11] httpwww3gehealthcarecouk[12] httpwww3gehealthcareplsimmediadownloadsukproduct

diagnostic20ecgambulatoryseer1000dcar emea brochureseer 1000 with cardioday english doc1286154 rev2 11-2013pdfParent=7BF194EDD5-D167-469C-B6A3-E21B8ABE83937D

[13] httpwwwmedtronicdiagnosticscom[14] httpwwwvicare-medicaldkadminUploadFileaspxpath=

UserUploadFilesMonitoreringCorventis20Event20recorderNuvant Specpdf

[15] httpomronhealthcarecomaupdf2HCG-801 Brochurepdf[16] httpwwwmrisafetycomSafetyInfovaspSafetyInfoID=249[17] S Tanaka K Motoi M Nogawa and K Yamakoshi ldquoA new

portable device for ambulatory monitoring of human postureand walking velocity using miniature accelerometers and gyro-scoperdquo in Proceedings of the 26th Annual International Confer-ence of the IEEE Engineering in Medicine and Biology Society(EMBC rsquo04) pp 2283ndash2286 San Francisco Calif USA Septem-ber 2004

[18] S Tanaka K Motoi M Nogawa and K Yamakoshi ldquoAnew portable device for ambulatory monitoring of humanposture and walking velocity using miniature accelerometersand gyroscoperdquo in Proceedings of the 26th Annual International

Conference of the IEEE Engineering in Medicine and BiologySociety (EMBC rsquo04) pp 2283ndash2286 September 2004

[19] A K Singh and U K Gorain ldquoDevelopment of vibrating discpiezoelectric gyroscoperdquo Defence Science Journal vol 54 no 3pp 387ndash393 2004

[20] httpswwwsparkfuncomdatasheetsComponentsIDG-300Datasheetpdf

[21] httpswwwsparkfuncomdatasheetsComponentsSMDData-sheet IDG500pdf

[22] httpwwwanalogcommediaentechnical-documentationdata-sheetsADXRS610pdf

[23] httpwwwmuratacomen-euproductssensorgyroscc2000[24] httpwww5epsondevicecomenproductsstandard gyro[25] H Cho and J H Lee ldquoA study on the optimal positions of

ECG electrodes in a garment for the design of ECG-monitoringclothing for malerdquo Journal of Medical Systems vol 39 article 952015

[26] K Zhang L Song and D Lu ldquoDesign of remote ECGmonitor-ing system based on GPRSrdquo in Proceedings of the 2011 Interna-tional Conference on Computer Science and Network Technology(ICCSNT rsquo11) pp 319ndash322 Harbin China December 2011

[27] Y Jang H W Noh I B Lee and Y Song ldquoA basic studyfor patch type ambulatory 3-electrode ECG monitoring systemfor the analysis of acceleration signal and the limb leads andaugmented unipolar limb leads signalrdquo in Proceedings of the32nd Annual International Conference of the IEEE EMBS pp3864ndash3867 Buenos Aires Argentina 2010

[28] B-H Kim Y-H Noh and D-U Jeong ldquoA wearable ECGmonitoring system using adaptive EMD filter based on activitystatusrdquo in Proceedings of the 29th IEEE International Conferenceon Advanced Information Networking and Applications Work-shops (WAINA rsquo15) pp 11ndash16 Gwangju South Korea March2015

[29] A A Altun and N Bascıfcı ldquoA wireless sensor network basedon zigbee for ECG monitoring systemrdquo in Proceedings of the5th International Conference on Application of Information andCommunication Technologies (AICT rsquo11) IEEE Baku Azerbai-jan October 2011

[30] E Valchinov A Antoniou K Rotas and N PallikarakisldquoWearable ECG system for health and sports monitoringrdquo inProceedings of the 4th International Conference on WirelessMobile Communication amp Healthcare (MOBIHEALTH rsquo14) pp63ndash66 November 2014

[31] J H Yap and D U Jeong ldquoDesign and implementation ofubiquitous ECGmonitoring system by using android tabletrdquo inUbiquitous Information Technologies and Applications vol 214of Lecture Notes in Electrical Engineering pp 269ndash277 SpringerBerlin Germany 2013

[32] Y-H Noh Y J Huei and D-U Jeong ldquoImplementation ofthe abnormal ECG monitoring system using heartbeat checkmap thechniquerdquo in Proceedings of the 2013 3rd InternationalConference on ITConvergence and Security (ICITCS rsquo13)MacauDecember 2013

[33] WWeiyaG Li L Zhanfeng andHGui ldquoResearch onwearableEeG monitoring system based on ZigBeerdquo in Proceedings ofthe IEEE Cross Strait Quad-Regional Radio Science and WirelessTechnology Conference pp 929ndash932 2011

[34] M-C Rosu ldquoImplementation for a WBAN-ECG monitoringsystem (Preliminary results)rdquo in Proceedings of the IEEE Inter-national Conference on Optimization of Electrical and ElectronicEquipment (OPTIM rsquo14) pp 823ndash826 Bran Romania May2014


[35] YWang RWunderlich and S Heinen ldquoDesign and evaluationof a novel wireless reconstructed 3-lead ECG monitoringsystemrdquo in Proceedings of the IEEE Biomedical Circuits andSystemsConference (BioCAS rsquo13) pp 362ndash365 IEEE RotterdamThe Netherlands November 2013

[36] A Acharyya K Maharatna B M Al-Hashimi and HTudugalle ldquoSimplified logic design methodology for fuzzymembership function based robust detection of maternal mod-ulus maxima location a low complexity Fetal ECG extractionarchitecture for mobile health monitoring systemsrdquo in Pro-ceedings of the IEEE International Symposium on Circuits andSystems (ISCAS rsquo11) pp 77ndash80 Rio de Janeiro Brazil May 2011

[37] Y Wang S Doleschel R Wunderlich and S Heinen ldquoAwearable wireless ECGmonitoring system with dynamic trans-mission power control for long-term homecarerdquo Journal ofMedical Systems vol 39 no 3 2015

[38] J Son B Kim and M Park ldquoLumbar cushion based real-time ECG sensing system for monitoring driverrsquos staterdquo inProceedings of the IEEE International Conference on ConsumerElectronics (ICCE rsquo15) pp 261ndash262 Las Vegas Nev USAJanuary 2015

[39] J E Gaxiola-Sosa N Mohsin A J Palliyali R Tafreshi andK Entesari ldquoA portable 12-lead ECG wireless medical systemfor continuous cardiac-activity monitoringrdquo in Proceedings ofthe 2nd Middle East Conference on Biomedical Engineering(MECBME rsquo14) pp 123ndash126 IEEE Doha Qatar February 2014

[40] M Hadjem O Salem and F Naıt-Abdesselam ldquoAn ECGmonitoring system for prediction of cardiac anomalies usingWBANrdquo in Proceedings of the 16th IEEE International Confer-ence on e-Health Networking Applications and Services (Health-com rsquo14) pp 441ndash446 Natal Brazil October 2014

[41] D J Harmah and D Kathirvelu ldquoAn ubiquitous miniaturizedandroid based ECG monitoring systemrdquo in Proceedings of theIEEE International Conference on Emerging Trends in Comput-ing Communication and Nanotechnology (ICE-CCN rsquo13) pp117ndash120 Tirunelveli India March 2013

[42] J Martinho L Prates and J Costa ldquoDesign and implementa-tion of a wireless multiparameter patient monitoring systemrdquoProcedia Technology vol 17 pp 542ndash549 2014

[43] Z Ping L Zhoucheng W Feng and J Hongyu ldquoNon-contactECGmonitoring based on capacitive electrodes springer worldcongress on medical physics and biomedical engineeringrdquo inWorld Congress on Medical Physics and Biomedical EngineeringMay 26ndash31 2012 Beijing China vol 39 of IFMBE Proceedingspp 1506ndash1509 Springer Berlin Germany 2013

[44] Z Tse C Dumoulin G Clifford et al ldquoCardiac MRI withconcurrent physiologicalmonitoring usingMRI-compatible 12-lead ECGrdquo Journal of Cardiovascular Magnetic Resonance vol14 supplement 1 article P231 2012

[45] N JMcDonaldHAAnumula EDuff andW Soussou ldquoNon-contact ECG system for unobtrusive long-termmonitoringrdquo inProceedings of the 34th Annual International Conference of theIEEE Engineering in Medicine and Biology Society (EMBS rsquo12)pp 1614ndash1618 Boston Mass USA September 2012

[46] T Chen E Mazomenos K Maharatna S Dasmahapatra andM Niranjan ldquoOn the trade-off of accuracy and computationalcomplexity for classifying normal and abnormal ECG in remoteCVDmonitoring systemsrdquo in Proceedings of the IEEEWorkshopon Signal Processing Systems (SiPS rsquo12) pp 37ndash42 IEEE QuebecCanada October 2012

[47] P Juan Pablo Tello O Manjarres M Quijano and A UlisesBlanco ldquoRemote monitoring system of ECG and temperature

signals using Bluetoothrdquo in Proceedings of the IEEE Interna-tional Symposium on Information Technologies in Medicine andEducation (ITME rsquo12) pp 860ndash863 Hakodate Japan August2012

[48] H Fernandez-Lopez J H Correia R Simoes and J A AfonsoldquoExperimental evaluation of IEEE 802154ZigBee for multi-patient ECG monitoringrdquo in Electronic Healthcare vol 69 ofLecture Notes of the Institute for Computer Sciences SocialInformatics and Telecommunications Engineering pp 184ndash191Springer 2011

[49] M Smolen P Kantoch P Augustyniak and P KowalskildquoWearable patient home monitoring based on ECG and ACCsensorsrdquo in 5th European Conference of the International Feder-ation for Medical and Biological Engineering vol 37 of IFMBEProceedings pp 941ndash944 Springer 2012

[50] J Lekkala T Salpavaara J Verho and J Riistama ldquoSimpleinductively coupled resonance sensor for ECG and heart ratemonitoringrdquo Procedia Engineering vol 5 pp 1438ndash1441 2010

[51] G Gupta ldquoPC based ECG monitoring systemrdquo in Proceedingsof the 2nd International Conference on Advances in RecentTechnologies in Communication and Computing (ARTCom rsquo10)pp 348ndash350 Kottayam India October 2010

[52] M S Kim Y C Cho S-T Seo C-S Son and Y-N Kim ldquoAuto-detection of R wave in ECG (electrocardiography) for patch-type ECG remote monitoring systemrdquo Biomedical EngineeringLetters vol 1 no 3 pp 180ndash187 2011

[53] A Loewe W H W Schulze Y Jiang M Wilhelms and ODossel ldquoDetermination of optimal electrode positions of awearable ECG monitoring system for detection of myocardialischemia a simulation studyrdquo Computing in Cardiology vol 38pp 741ndash744 2011

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[55] J Dangi and R C Gurjar ldquoAn Ecg instrumentation amplifierwith improved Cmrr and gain using 18120583m technologyrdquo inProceedings of the 11th IRF International Conference pp 92ndash95Pune India October 2015

[56] D J Moni and N Gopalakrishnan ldquoA low power CMOSelectrocardiogram amplifier design using 018 120583m CMOS tech-nologyrdquo International Journal of Advancements in Research ampTechnology vol 2 no 2 pp 1ndash5 2013

[57] Y Tseng Y Ho S Kao and C Su ldquoA 009 W low powerfront-end biopotential amplifier for biosignal recordingrdquo IEEETransactions on Biomedical Circuits and Systems vol 6 no 5pp 508ndash516 2012

[58] M Y Ren C X Zhang andD S Sun ldquoDesign of CMOS instru-mentation amplifierrdquo in Proceedings of the 2012 InternationalWorkshop on Information and Electronics Engineering (IWIEErsquo12) vol 29 pp 4035ndash4039 Harbin China March 2012

[59] L Xiu and Z Li ldquoLow-power instrumentation amplifier ICdesign for ECG system applicationsrdquo in Proceedings of the Inter-national Workshop on Information and Electronics Engineering(IWIEE rsquo12) vol 29 pp 1533ndash1538 Harbin China March 2012

[60] J-Y Um J-Y Sim and H-J Park ldquoA gate-leakage insensi-tive 07-V 233-nW ECG amplifier using non-feedback PMOSpseudo-resistors in 013-120583mN-well CMOSrdquo Journal of Semicon-ductor Technology and Science vol 10 no 4 pp 309ndash315 2010

[61] W-S Wang Z-C Wu H-Y Huang and C-H Luo ldquoLow-power instrumental amplifier for portable ECGrdquo in Proceedings


of the IEEECircuits and Systems International Conference Testingand Diagnosis (ICTD rsquo09) Chengdu China April 2009

[62] S P Almazan L I Alunan F R Gomez J M Jarillas MT Gusad and M Rosales ldquoMonolithic CMOS current-modeinstrumentation amplifiers for ECG signalsrdquo in Proceedings ofthe 13th International Conference on Biomedical Engineering(ICBME rsquo08) vol 23 pp 846ndash850 Singapore December 2008

[63] C Nanda J Mukhopadhyay D Mandai and S ChakrabartildquoA CMOS instrumentation amplifier with low voltage and lownoise for portable ECG monitoring systemsrdquo in Proceedings ofthe IEEE International Conference on Semiconductor Electronics(ICSE rsquo08) pp 54ndash58 Johor Bahru Malaysia November 2008

[64] J-C Liou T-T ShihW-C Lin and Y-C Huang ldquoNoninvasiveECG and EMG Electrode system for Health Monitoring andScience technology applicationrdquo in Proceedings of the IEEEInternational Conference on Consumer Electronics (ICCE-TWrsquo15) Taipei Taiwan June 2015

[65] S Shebi Ahammed and B C Pillai ldquoDesign of Wi-Fi basedmobile Electrocardiogrammonitoring system on concerto plat-formrdquo Procedia Engineering vol 64 pp 65ndash73 2013

[66] R-D Chiu and S-H Wu ldquoA BAN system for realtime ECGmonitoring from wired to wireless measurementsrdquo in Pro-ceedings of the IEEE Wireless Communications and NetworkingConference (WCNC rsquo11) pp 2107ndash2112 IEEE Cancun MexicoMarch 2011

[67] H Gao X Duan X Guo A Huang and B Jiao ldquoDesign andtests of a smartphones-based multi-lead ECG monitoring sys-temrdquo in Proceedings of the 35th Annual International Conferenceof the IEEE Engineering in Medicine and Biology Society (EMBCrsquo13) pp 2267ndash2270 Osaka Japan July 2013

[68] M-C Rosu ldquoPreliminary evaluation for an ECG monitoringsystemrdquo in Proceedings of the 6th International Conference onElectronics Computers and Artificial Intelligence (ECAI rsquo14) pp73ndash80 IEEE Bucharest Romania October 2014

[69] M Zeng I-Y Chung J-A Lee and J-G Lee ldquoAn on-nodeintelligence based energy efficient ECG monitoring systemrdquo inProceedings of the International Conference on ICT Convergence(ICTC rsquo11) pp 401ndash405 IEEE Seoul South Korea September2011

[70] T Komensky M Jurcisin K Ruman O Kovac D Laquaand P Husar ldquoUltra-wearable capacitive coupled and commonelectrode-free ECG monitoring systemrdquo in Proceedings of the34th Annual International Conference of the IEEE Engineering inMedicine and Biology Society (EMBS rsquo12) pp 1594ndash1597 IEEESan Diego Calif USA September 2012

[71] O Ozkaraca A H Isik and I Guler ldquoDetection real timeprocessing and monitoring of ECG signal with a wearablesystemrdquo in Proceedings of the International Symposium onInnovations in Intelligent SysTems and Applications (INISTA rsquo11)pp 424ndash427 tur June 2011

[72] M K Islam M A Shoeb T Ahammad and T F NowrinldquoEmbedded programmable web-based ECG monitoring ampdetection system using a fast algorithmrdquo in Proceedings ofthe International Conference on Bioinformatics and BiomedicalTechnology (ICBBT rsquo10) pp 156ndash159 IEEE Chengdu ChinaApril 2010

[73] httpwwwskintactcom[74] httpwwwmedgadgetcom[75] httpwwwmeddeviceonlinecom[76] J-Y Baek J-H An J-M Choi K-S Park and S-H Lee ldquoFlex-

ible polymeric dry electrodes for the long-term monitoring of

ECGrdquo Sensors andActuators A Physical vol 143 no 2 pp 423ndash429 2008

[77] A Gruetzmann S Hansen and J Muller ldquoNovel dry electrodesfor ECGmonitoringrdquo Physiological Measurement vol 28 no 11pp 1375ndash1390 2007

[78] R Matthews N J McDonald I Fridman P Hervieux and TNielsen ldquoNonintrusive wearable bioelectrodes for monitoringthe heart and brainrdquo Sensors 2007 httpwwwsensorsmagcomspecialty-marketsmedical-devicesnonintrusive-wearable-bioelectrodes-monitoring-heart-and-bra-1412

[79] H W Sharma and M Singh ldquoDesign and development ofheart rate monitoring device with reduction of motion artefactusing 3-axis accelerometerrdquo International Journal of EmergingTechnology and Advanced Engineering vol 4 no 7 pp 448ndash4532014

[80] C-H Lin S-Y Chen C-C Yang et al ldquoStructural healthmonitoring of bridges using cost-effective 1-axis accelerome-tersrdquo in Proceedings of the 2014 9th IEEE Sensors ApplicationsSymposium (SAS rsquo14) pp 24ndash27 Queenstown New ZealandFebruary 2014

[81] H Gjoreski A Rashkovska S Kozina M Lustrek and MGams ldquoTelehealth using ECG sensor and accelerometerrdquo inProceedings of the 37th International Convention on Informationand Communication Technology Electronics and Microelectron-ics (MIPRO rsquo14) pp 270ndash274 May 2014

[82] V Dhivya Poorani K Ganapathy and V Vaidehi ldquoSensorbased decision making inference system for remote healthmonitoringrdquo in Proceedings of the International Conference onRecent Trends in Information Technology (ICRTIT rsquo12) pp 337ndash342 Chennai India April 2012

[83] E KantochM Smolen P Augustyniak and P Kowalski ldquoWire-less body area network system based on ECG and accelerometerpatternrdquo Computing in Cardiology vol 38 pp 245ndash248 2011

[84] A Dinh ldquoHeart activity monitoring on smartphonerdquo in Pro-ceedings of the International Conference on Biomedical Engineer-ing and Technology (IPCBEE rsquo11) pp 45ndash49 2011

[85] J Lee J Jung J Lee and Y T Kim ldquoDiagnostic device for acutecardiac disease using ECG and accelerometerrdquo in Proceedingsof the 5th International Conference on Information Science andApplications (ICISA rsquo14) pp 1ndash3 IEEE Seoul South Korea May2014

[86] J Penders M Altini J van de Molengraft F Yazicioglu andC Van Hoof ldquoA low-power wireless ECG necklace for reliablecardiac activity monitoring on-the-moverdquo in Proceedings of the33rd IEEE EMBS Annual International Conference (EMBC rsquo11)Boston Mass USA 2011

[87] P Augustyniak M Smolen Z Mikrut and E Kantoch ldquoSeam-less tracing of human behavior using complementary wearableand house-embedded sensorsrdquo Sensors vol 14 no 5 pp 7831ndash7856 2014

[88] A M Khan M H Siddiqi and S-W Lee ldquoExploratory dataanalysis of acceleration signals to select light-weight and accu-rate features for real-time activity recognition on smartphonesrdquoSensors vol 13 no 10 pp 13099ndash13122 2013

[89] A Muaremi J Seiter G Troster and A Bexheti ldquoMonitor andunderstand pilgrims data collection using smartphones andwearable devicesrdquo in Proceedings of the 2013 ACMConference onPervasive and Ubiquitous Computing Adjunct Publication (Ubi-Comp rsquo13 Adjunct) pp 679ndash688 ACM Zurich Switzerland2013

[90] W V Shi and M Zhou ldquoRecent advances of sensors forpacemakersrdquo in Proceedings of the International Conference on


Networking Sensing andControl (ICNSC rsquo11) pp 520ndash525 IEEEDelft The Netherlands April 2011

[91] T Grosse-Puppendahl E Berlin and M Borazio ldquoEnhancingaccelerometer-based activity recognition with capacitive prox-imity sensingrdquo in Ambient Intelligence Springer 2012

[92] M-Z Poh N C Swenson and R W Picard ldquoMotion-tolerantmagnetic earring sensor andwireless earpiece forwearable pho-toplethysmographyrdquo IEEETransactions on Information Technol-ogy in Biomedicine vol 14 no 3 pp 786ndash794 2010

[93] S J Preece J Y Goulermas L P J Kenney and D Howard ldquoAcomparison of feature extraction methods for the classificationof dynamic activities from accelerometer datardquo IEEE Transac-tions on Biomedical Engineering vol 56 no 3 pp 871ndash879 2009

[94] M Jafari Tadi T Koivisto M Pankaala and A PaasioldquoAccelerometer-based method for extracting respiratory andcardiac gating information for dual gating during nuclearmedicine imagingrdquo International Journal of Biomedical Imagingvol 2014 Article ID 690124 11 pages 2014

[95] A M Chan N Ferdosi and R Narasimhan ldquoAmbulatory res-piratory rate detection using ECG and a triaxial accelerometerrdquoin Proceedings of the 35th Annual International Conference of theIEEE Engineering in Medicine and Biology Society (EMBC rsquo13)pp 4058ndash4061 Osaka Japan July 2013

[96] G-Z Liu Y-W Guo Q-S Zhu B-Y Huang and L WangldquoEstimation of respiration rate from three-dimensional acceler-ation data based on body sensor networkrdquo Telemedicine Journaland e-Health vol 17 no 9 pp 705ndash711 2011

[97] Y Okada T Y Yoto T Suzuki S Sakuragawa and T SugiuraldquoWearable ECG recorder with acceleration sensors formonitor-ing daily stress office work simulation studyrdquo in Proceedings ofthe 35th Annual International Conference of the IEEE Engineer-ing in Medicine and Biology Society (EMBC rsquo13) pp 4718ndash4721July 2013

[98] L Oudre A Lung-Yut-Fong and P Bianchi ldquoSegmentationof accelerometer signals recorded during continuous treadmillwalkingrdquo in Proceedings of the 19th European Signal ProcessingConference (EUSIPCO rsquo11) pp 1564ndash1568 Barcelona SpainSeptember 2011

[99] E Sejdic K A Lowry J BellancaM S Redfern and J S BrachldquoA Comprehensive Assessment of Gait Accelerometry Signalsin Time Frequency and Time-Frequency Domainsrdquo IEEETransactions on Neural Systems and Rehabilitation Engineeringvol 22 no 3 pp 603ndash612 2014

[100] F Studnicka P Seba D Jezbera and J Krız ldquoContinuousmoni-toring of heart rate using accelerometric sensorsrdquo inProceedingsof the 35th International Conference on Telecommunications andSignal Processing (TSP rsquo12) pp 559ndash561 IEEE Prague CzechRepublic July 2012

[101] A I Bhuyan and T CMallick ldquoGyro-accelerometer based con-trol of a robotic arm using AVRmicrocontrollerrdquo in Proceedingsof the 9th International Forum on Strategic Technology (IFOSTrsquo14) pp 409ndash413 IEEE Coxrsquos Bazar Bangladesh October 2014

[102] Y Chen J M Oliveira and I W Hunter ldquoSensor architecturefor a two-actuator robotic endoscope tiprdquo in Proceedings of the33rd Annual International Conference of the IEEE Engineering inMedicine and Biology Society (EMBS rsquo11) pp 8340ndash8343 IEEEBoston Mass USA September 2011

[103] C Liu and Z Wang ldquoDesign and realization of data acquiringsystem for vehicle speed sensor and gyroscoperdquo in Proceedingsof the 2nd IEEE International Conference Information Manage-ment and Engineering (ICIME rsquo10) April 2010

[104] G Li F Wang G Xiao G Wei P Zhang and X LongldquoTemperature compensation method using readout signals ofring laser gyroscoperdquo Optics Express vol 23 no 10 pp 13320ndash13332 2015

[105] D Xia S Chen and S Wang ldquoDevelopment of a prototypeminiature silicon microgyroscoperdquo Sensors vol 9 no 6 pp4586ndash4605 2009

[106] X Chen X Hu R Ren et al ldquoNoninvasive ambulatorymonitoring of the electric and mechanical function of heartwith amultifunction wearable sensorrdquo in Proceedings of the 38thAnnual IEEE Computer Software and Applications ConferenceWorkshops (COMPSACW rsquo14) pp 662ndash667 Vasteras SwedenJuly 2014

[107] K Brzostowski J Drapala and J Swiatek ldquoData-driven modelsfor eHealth applicationsrdquo International Journal of ComputerScience and Artificial Intelligence vol 3 no 1 pp 1ndash9 2013

[108] M Khazraee A R Zamani M Hallajian et al ldquoA novelhardware implementation for joint heart rate respiration rateand gait analysis applied to body area networksrdquo in Proceedingsof the IEEE International Symposium on Circuits and Systems(ISCAS rsquo13) pp 1889ndash1892 Kottayam India May 2013

[109] G Gargiulo P Bifulco M Cesarelli et al ldquoAn ultra-highinput impedance ECG amplifier for long-term monitoring ofathletesrdquo Medical Devices Evidence and Research vol 3 no 1pp 1ndash9 2010

[110] T J Sullivan S R Deiss and G Cauwenberghs ldquoA low-noise non-contact EEGECG sensorrdquo in Proceedings of theIEEE Biomedical Circuits and Systems Conference HealthcareTechnology (BiOCAS rsquo07) pp 154ndash157 November 2007

[111] J Gomez-Clapers E Serrano-Finetti R Casanella and RPallas-Areny ldquoCan driven-right-leg circuits increase interfer-ence in ECG amplifiersrdquo in Proceedings of the 33rd AnnualInternational Conference of the IEEE Engineering in Medicineand Biology Society (EMBS rsquo11) pp 4780ndash4783 Boston MassUSA September 2011

[112] A Q Bhat V Kumar and S Kumar ldquoDesign of ECG dataacquisition systemrdquo International Journal of Advanced Researchin Computer Science and Software Engineering vol 3 no 4 pp676ndash680 2013

[113] K Wang S Ma J Feng W Zhang M Fan and D ZhaldquoDesign of ECG signal acquisition system based on DSPrdquo inProceedings of the International Workshop on Information andElectronics Engineering Procedia Engineering vol 29 pp 3763ndash3767 Elsevier Amsterdam Netherlands 2012

[114] E Richard and A D C Chan ldquoDesign of a gel-less two-electrode ECG monitorrdquo in Proceedings of the IEEE Interna-tional Workshop on Medical Measurements and Applications(MeMeA rsquo10) pp 92ndash96 May 2010

[115] J Krishnan N D Khambete A Rajan and B BenjaminldquoLow power multiparameter biopotential amplifier systemrdquoInternational Journal of Science and Research vol 2 no 11 pp186ndash189 2013

[116] M Burke and C Jassambo ldquoAn ultra-low power dry-electrodeECG amplifier having optimized low-frequency response andCMRRrdquo Recent Researches in Circuits and Systems pp 54ndash592010

[117] C Assambo and M J Burke ldquoAmplifier input impedancein dry electrode ECG recordingrdquo in Proceedings of the 31stAnnual International Conference of the IEEE Engineering inMedicine and Biology Society (EMBC rsquo09) pp 1774ndash1777 IEEEMinneapolis Minn USA September 2009


[118] O T Inan and G T A Kovacs ldquoAn 11 120583 w two-electrodetransimpedance biosignal amplifier with active current feed-back stabilizationrdquo IEEE Transactions on Biomedical Circuitsand Systems vol 4 no 2 pp 93ndash100 2010

[119] EM Spinelli R Pallas-Areny andMAMayosky ldquoAC-coupledfront-end for biopotential measurementsrdquo IEEE Transactionson Biomedical Engineering vol 50 no 3 pp 391ndash395 2003

[120] Y-W Bai C-Y Cheng C-K Lu C-H Huang Y-T Chenand Y-N Lin ldquoAdjustable 60Hz noise reduction and ECGsignal amplification of a remote electrocardiogram systemrdquo inProceedings of the 20th IEEE Instrumentation and MeasurementTechnology Conference (IMTC rsquo03) pp 197ndash202 Vail ColoUSA May 2003

[121] S SongM Rooijakkers P Harpe et al ldquoA low-voltage chopper-stabilized amplifier for fetal ECG monitoring with a 141 powerefficiency factorrdquo IEEE Transactions on Biomedical Circuits andSystems vol 9 no 2 pp 237ndash247 2015

[122] C-C Tu and T-H Lin ldquoAnalog front-end amplifier for ECGapplications with feed-forward EOS cancellationrdquo in Proceed-ings of the International SymposiumonVLSIDesign Automationand Test (VLSI-DAT rsquo14) Hsinchu Taiwan April 2014

[123] S Wang Y Wang L Chen et al ldquoA 192nW inverter-basedchopper instrumentation amplifier for micropower ECG appli-cationsrdquo inProceedings of the 12th IEEE International Conferenceon Solid-State and Integrated Circuit Technology (ICSICT rsquo14)October 2014

[124] J Zhang L Wang and B Li ldquoDesign of low-offset low-power CMOS amplifier for biosensor applicationrdquo Journal ofBiomedical Science and Engineering vol 2 no 7 pp 538ndash5422009

[125] D Rowlands D A James C Vanegas S Rao and P LisnerldquoDesign and fabrication of an ECG amplifier on silicon usingstandard CMOS processrdquo in Proceedings of the Second IEEEInternational Conference on Sensors IEEE Sensors 2003 pp1348ndash1352 October 2003

[126] B Lee and T Higman ldquo12V constant-gm rail-to-rail CMOSOp-Amp input stage with new overlapped transition regionstechnique for ECG amplifierrdquo in Proceedings of the 35th AnnualInternational Conference of the IEEE Engineering in Medicineand Biology Society (EMBC rsquo13) pp 3451ndash3454 IEEE OsakaJapan July 2013

[127] M Ghamati andMMaymandi-Nejad ldquoA low-noise low-powerMOSFET only electrocardiogram amplifierrdquo in Proceedings ofthe 21st Iranian Conference on Electrical Engineering (ICEE rsquo13)Mashhad Iran May 2013

[128] C-CWuW-CKuoH-JWang et al ldquoApliable and batterylessreal-time ECGmonitoring system-in-a-patchrdquo inProceedings ofthe International Symposium on VLSI Design Automation andTest (VLSI-DAT rsquo15) IEEE April 2015

[129] D Pani A Dessı J F Saenz-Cogollo G Barabino B Fraboniand A Bonfiglio ldquoFully textile PEDOTPSS based electrodesfor wearable ECG monitoring systemsrdquo IEEE Transactions onBiomedical Engineering vol 63 no 3 pp 540ndash549 2016

[130] httpwwwticom[131] httpwwwanalogcom[132] D M D Ribeiro M F M Colunas F A F Marques J M

Fernandes and J P S Cunha ldquoA real time wearable ECG andcontinous blood pressure monitoring system for first respon-dersrdquo in Proceedings of the 33rd Annual International Conferenceof the IEEE Engineering in Medicine and Biology Society (EMBSrsquo11) pp 6894ndash6898 Boston Mass USA September 2011

[133] K Wang S Ma J Feng W Zhang M Fan and D ZhaoldquoDesign of ECG signal acquisition system based on DSPrdquoProcedia Engineering vol 29 pp 3763ndash3767 2012

[134] J N Chi Y T Yan M C Liu and L Yang ldquoThe developmentof a Portable ECG monitor based on DSPrdquo in Proceedings ofthe ELSEVIER International Conference on Medical Physicsand Biomedical Engineering (ICMPBE rsquo12) vol 33 of PhysicsProcedia pp 765ndash774 Qingdao China 2012

[135] J Chai ldquoThe design of mobile ECGmonitoring systemrdquo in Pro-ceedings of the 4th IEEE International Conference on ElectronicsInformation and Emergency Communication (ICEIEC rsquo13) pp148ndash151 IEEE Beijing China November 2013

[136] G Yang X Cai F Wang S Cu and L Zhao ldquoResearch ofportable ECG monitoring devicerdquo in Advances in ComputerCommunication Control and Automation vol 121 of LectureNotes in Electrical Engineering pp 213ndash220 Springer BerlinGermany 2011

[137] D Campillo H Torres R Gonzalez K Valdes and R LopezldquoA portable device for a modular system of patient ECGmonitoringrdquo Computing in Cardiology vol 41 pp 1077ndash10792014

[138] C Ken and L Xiaoying ldquoAZigbee basedmesh network for ECGmonitoring systemrdquo in Proceedings of the 4th International Con-ference on Bioinformatics and Biomedical Engineering (iCBBErsquo10) pp 1ndash4 Chengdu China June 2010

[139] E B Alzate and FMMartinez ldquoECGmonitoring system basedon ARM9 andmobile phone technologiesrdquo in Proceedings of theIEEE Andean Council International Conference (ANDESCONrsquo10) September 2010

[140] W Shin Y D Cha and G Yoon ldquoECGPPG integer signalprocessing for a ubiquitous health monitoring systemrdquo Journalof Medical Systems vol 34 no 5 pp 891ndash898 2010

[141] X Guo W Chen X Xu and H Li ldquoThe research of portableECG monitoring system with USB host interfacerdquo in Proceed-ings of the IEEE 3rd International Conference on BioMedicalEngineering and Informatics (BMEI rsquo10) pp 1614ndash1618 YantaiChina October 2010

[142] httpwwwatmelcomproductssmart-energywireless-com-municationsdefaultaspx

[143] httpswwwlsrcomwhite-paperssoc-vs-sdr-for-wireless-prod-uct-design


Table 1 Comparison among Holter monitor ELR and ILR

Advantages Limitations Indications Diagnostic yield

Holter monitor Low cost continuousmonitoring

Short duration ofmonitoring with lowdiagnostic yield

Patients with very frequentsymptoms (ge1 week) 6ndash22

External looprecorder

Retrospective andprospective ECG recordspossibility to recordasymptomatic arrhythmiasautomatically

Poor recordings poorpatient compliance towearing device continuousdevice maintenancerequired

Compliant patients withintersymptom interval le 4weeks

24ndash47

Implantableloop recorder

Prolonged monitoringwithout external electrodeshighest diagnostic yield

Invasive implantation withrisk of local complicationshigh cost

Early phase of evaluation ofpatients with recurrentsyncope of uncertain originthat have absence of highrisk criteria that requireimmediate hospitalizationor intensive evaluation anda likely recurrence withindevice battery longevity

43ndash78

ECG electrodes IA Filtering AD

Signal processing unit

PClaptopmobile

Accelerometer gyroscope

Figure 1 Block diagram of external cardiac loop recorder

developedThis is also referred to as eventmonitor or externalloop recorder (ELR) The ELR is smaller than Holter in sizeand is attached to the patient through chest electrodes andrecords the data when it is activated by the patient or by anautomatic trigger that detects irregular heart rates It is usedfor monitoring up to 14ndash30 days The cost of ELR is $627and cost per diagnosis using ELR is around $2659 [7] Theuse of ELR avoids the surgical implantation of electrodesBut the activation of the device every time by the patientis difficult unless the autotrigger is used The autotriggeractivates the device as it is programmed which is built intothe monitor Therefore during infrequent symptoms thereis a more chance of missing the activation of the deviceThismay not give enough information for effective diagnosisAfter recording using any of the above-mentioned systemsthe data is sent to the central monitoring station where thedata is loaded in the computer and analysed Finally thereports are sent to the doctor for a final decision or for furthertests to detect and confirm the disease As mentioned aboveELR is providing the noninvasive diagnosis by long-termmonitoring Even the cost of design is less the ELR test cost ishigh Further the recorded data has to be sent to the specialistto analyse the data which increase the cost further And thereis no option for autosending the recorded data or analysed

data to the doctor The comparison among Holter ILR andELR is given [8] in Table 1

In Table 2 some of the available ILR and ELR products aregiven [5 9ndash16]

The mentioned products in Table 2 are very expensiveand most of them are not significantly available in IndiaDistributors are there all over India but they are providingonly a few products like Medtronic SpiderView SEEQ MCTPiix NUVANT MCT GE Healthcare MARS SEER 1000SEER Light Omron HCG801 and BPL cardiac loop recordermonitor Therefore a systematic review on internal parts ofECG monitoring system is required to design a cost effec-tive ambulatory ECG monitoring system with an accuratemeasurement portable and wearable one as explained in thefollowing sections

2 Designing of External CardiacLoop Recorder

The design of external cardiac loop recorder consists of ECGelectrodes instrumentation amplifier filtering analog to dig-ital converter and signal processing unit PClaptopmobileis also used to analyse the data The major blocks andconnection of them are shown in Figure 1

























Au + Ti layer

Wire connection

Copper wire

Velcro

PDMS substrate




(a) (b)












550Hz








Bosch BMA180VDD =

































3 Discussion





















5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References












































































































































































Au + Ti layer

Wire connection

Copper wire

Velcro

PDMS substrate




(a) (b)












550Hz








Bosch BMA180VDD =

































3 Discussion





















5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References
































































































































































Au + Ti layer

Wire connection

Copper wire

Velcro

PDMS substrate




(a) (b)












550Hz








Bosch BMA180VDD =

































3 Discussion





















5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References





















































































































































(a) (b)












550Hz








Bosch BMA180VDD =

































3 Discussion





















5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References


























































































































































550Hz








Bosch BMA180VDD =

































3 Discussion





















5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References









































































































































































3 Discussion





















5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References




























































































































































3 Discussion





















5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References





































































































































































5









and sticky gel






in midaxillary line


Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References





















































































































































Table 6 Continued






[37] 3 ECG


from midline















4 Conclusion






















Competing Interests


References








































































































































































Competing Interests


References






















































































































































Competing Interests


References












































































































































































































































































































































































































































Documents

An Engineering Perspective of External Cardiac Loop Recorder: A … · 2016-11-21 · ReviewArticle An Engineering Perspective of External Cardiac Loop Recorder: A Systematic Review