Taste 17. N=Normal Group. H=Harmonic. Max.=Maximum Amplitude Value. Min.=Minimum Amplitude
Value. f=Fundamental of 10 Hz for harmonic #1. %=Per Cent Amplitude Values.

(N)
SR-CMs5-STy — (%)
Max. Min. A Max. Min. H Max. Min. H Max.

fl 132 12.418 4,153] .05? [iol] .369].075 [isi
2 Te 5.786 33 +534] .130 H102] £340 2936 152
z 2.490 |] 53 53 | 098 153
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3 2.979 553 || 57
38 «576 28
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11] 2.073] .432 |} on
12] 2.011 | .438 || 62
1 1,663 +329 |] 63
Wb] 1.527 | £322 |] of
15] 1.428 +105 || 65
16] 1.241 | 262 |] 66
17 | 5.346 +200 |] 07
18] 4,776 | .171 |] 68
19 | 8.705 2184 |] oc
20| 2.415
21] 1.932
22 +855
23] .871
ok 2775,
25] .751
26] .914
27 -631
28 628
29 2597
0743
31 501
32 600
33 600
34 “122
35 het
36 425
37 | .420
3 AST
39 | 422
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AMPLITUDE FREQUENCY DIFFERENCES IN A SUPINE RESTING
SINGLE-LEAD ELECTROCARDIOGRAM OF NORMAL
VERSUS CORONARY HEART DISEASED MALES

I. Introduction

The Federal Aviation Administration (FAA)
is responsible for the periodic examination of
approximately 750,000 airmen and for the medi-
cal disqualification of those manifesting any of
several specified disorders which are incompatible
with aviation safety. In addition, FAA Order
9430.2A initiated in 1965 a specific health pro-
gram designed to provide health maintenance
and preventive medicine on behalf of the Air
Traffic Controller Specialist (ATCS) population.
One of the serious medical foci for these two
responsibilities continues to be coronary heart
disease (CHD).1* Details concerning the high
prevalence of diagnosed and silent CHD, the
relationship of sudden CHD incapacitation to
critical aviation activities, the relevance of early
CHD detection to aviation safety and the de-
sirability of preventive maintenance of optimum
cardiovascular health in all major segments of
the airman population have been presented in
two previous reports.’ ¢

Medically defined, the main diagnostic criteria
of CHD include: (1) angina pectoris and/or;
(2) myocardial infarction and/or; (3) a positive
angiocardiogram of >50% luminal atheroscle-
rotic obstruction of one or more major coronary
arteries..® A resting, standard 12-lead clinical
electrocardiogram (ECG) alone is not always
successful in detecting CHD. In many instances,
it may be normal in persons with documented
medical histories of angina pectoris,‘*° positive
angiocardiography®’*TM-** and previous myo-
cardial infarction.” 2? **** Further, it may be
normal closely antecedent to confirmed myocar-
dial infarction and/or CHD death.**** In gen-
eral, exercise ECG tests excel the resting ECG
for detection of CHD. However, even in the
best contemporary exercise ECG tests, a false
positive/false negative total error of at least 10%
is not unusual.® 7 15-* 25-7 40-45 Because an airman

with undetected occult/covert CHD would be no
less vulnerable to sudden CHD incapacitation/
death than his vulnerable overt counterpart,?**°
and because this type of sudden incapacitation/
death is most susceptible to avoidance if detected
and treated prior to the assault of a major car-
diac crisis, any advance in the technology of
early detection of CHD should be highly desir-
able. Therefore, research was initiated to probe
the possibility of using amplitude/frequency
(A/F) analysis of high fidelity ECG recordings
as a basis for improved screening discernment
of the normal versus CHD states.

The rationale for this approach, the results of
our early probing experiments and the previously
published studies of other investigators in this
general area have been presented and discussed
in a previous report.‘* Our research in the area
of A/F analysis of the ECG signal was encour-
aged by the fact that the serious limitations in
equipment and techniques which contemporarily
handicapped the earlier efforts in this area‘?
no longer exist.***

Il. Methods

A. Selection of Normal Subjects, Thirty
normal males, free of CHD, were selected for
this study. Normality was defined mainly on
the basis of “coronary profile” parameters estab-
lished in the Framingham Heart Study (FHS).**
The normality parameters and their respective
quantitative/qualitative criteria are shown in
Table 1. Rejection of any candidate for the
normal group was considered mandatory if based
on any of the first 12 parameters of Table 1.
Rejection on the basis of parameters 13-31 was
subject to medical review by CAMI staff physi-
cians. ATC trainees and employees of the FAA
Aeronautical Center, Oklahoma City, comprised
the two sources of volunteer candidates for the



Tante 20. CHD=Coronary Heart Disease Group, H=Harmonic. Max.=Maximum Amplitude Value. Min.=
Minimum Amplitude Value. f=Fundamental of 10 Hz for harmonic #1. %=Per Cent Amplitude Values.

(CHD)
SR- CMs- ST79 (%)
H_ Max. Min. H Max. Min. H Max. Min. H Max. Min.

1| 29.298
2| 11.922
| 3:65
5 A78R5
6 2:33
7 .

8| 2.767
9] 2.100
10] 2,092
1} 1.822
12{| 5.490
13| 2.856
1 1
15 6
16 0
1 07
1 5
19 2
20 1
al 53
22 J
Be | Tee8
25 28
26 3
27 2
28] _.720
29 | 3.166
30 635,
31 ed
32 807
33 611
34 ~680
35 +716
36 606
37 | 2.095
3)
Oo} 675
Al 2459
4a 2572
43 498
i +539
5 | 1.137
46 857
47] .621
48) £533
49) .586
50 ~423

21



19.

20.

21,

23,

24,

25.

26.

27.

28.

29.

31.

. Anderssen,

tion with Electrocardiographic Response to Meas-
ured Exercise, AM. J. CARDIOL., 18:160, 1966.

McHenry, P. L., J. F. Phillips and S. K, Knoebel:
Correlation of Computer-Quantitated Treadmill
Exercise Electrocardiogram with Arteriographic
Location of Coronary Artery Disease, AM. J.
CARDIOL., 30:747, 1972.

Roitman, D., W. B. Jones and L. TT. Sheffield: Com-
parison of Submaximal Exercise ECG Test with
Coronary Cineangiocardiogram, ANN. INT. MED.,
72 :641, 1970.

Cohn, P. F., R. Gorlin, P. 8. Vokonas, R. A. Williams
and M. V. Herman: A Quantitative Clinical Index
for the Diagnosis of Symptomatic Coronary Artery
Disease, NEW ENG. J. MED., 286:901, 1972.

Fitzgibbon, G. M., G. W. Burggraf, T. D, Groves and
J. O. Parker: A Double Master’s Two-Step Test:
Clinical, Angiographic and Hemodynamic Correla-
tions, ANN. INT. MED., 74 :509, 1971.

Benchimol, A. C. L. Harris, K. B. Desser, B. T.
Kwee and S. D. Promisloff: Resting Electrocardio-
gram in Major Coronary Artery Disease, JAMA,
224 31489, 1973.

McConahay, D. R., B. D, McCallister, F. J. Haller-
mann and R. BE, Smith: Comparative Quantitative
Analysis of the Electrocardiogram and the Vector-
cardiogram: Correlations with the Coronary Arterio-
gram, CIRC,, 42:245, 1970.

Kassebaum, D. G., K. I. Sutherland and M. P. Jud-
kins: A Comparison of Hypoxemia and Exercise
Electrocardiography in Coronary Artery Disease,
AM. HEART J., 75:759, 1968.

Hultgren, H., A. Calciano, F, Platt and H. Abrams:
A Clinical Evaluation of Coronary Arteriography,
AM. J. MED., 42:228, 1967.

Cohn, P. F., P. S. Vokonas, A. S. Most, M. V. Herman
and R. Gorlin: Diagnostic Accuracy of Two-Step
Postexercise ECG: Results in 305 Subjects Studied
by Coronary Arteriography, JAMA, 220:501, 1972
Kannel, W. B., P. M. McNamara, M. Feinlieb and
'T, R. Dawber: The Unrecognized Myocardial Infare-
tion: Fourteen-Year Follow-Up Experience in the
Framingham Study, GERIATRICS, 25:75, 1970.
Stokes, J. and T. R. Dawber: The “Coronary”: The
Frequency and Clinical Characteristics of Unrecog-
nized Myocardial Infarction in the Framingham
Heart Study, ANN. INT. MED., 50:1859, 1959,

. Master, A. M. and A. J. Geller: The Extent of Com-

pletely Asymptomatic Coronary Artery Disease, AM.
J, CARDIOL. 23:173, 1969.

East, T. and S. Oram: Cardiac Pain with Recovery
of the T. Wave, BRIT. HEART J., 10:263, 1948.

N. and 0, Skaeggestad: The Electro-
cardiogram in Patients with Previous Myocardial
Infarction, ACTA MED. SCAND., 176:123, 1964.

Burns-Cox, ©. J.: The Return to Normal of the
Electrocardiogram after Myocardial Infarction,
LANCET, 1:1194, 1967.

27

36.

37.

39.

40.

41.

43.

44,

45.

aT.

49,

Kaplan, B. M. and D. M. Berkson: Serial Electro-
cardiograms after Myocardial Infarction, ANN. INT.
MED., 60:430, 1964.

Allison, R. B., F. L. Rodriguez, E. A. Higgins, Jr.,
J. P. Leddy, W. H. Abelmann, L. B. Ellis and 8. L.
Robbins: Clinicopathologic Correlations in Coronary
Atherosclerosis, CIRC., 27:170, 1963.

Skaeggestad, O. and K. Molne: The Electrocardio-
gram in Patients with Healed Myocardial Infarction
Disclosed at Autopsy, ACTA MED, SCAND., 179:23,
1966.

Pell, S. and G. A. D’Alonzo: A Three-Year Study of
Myocardial Infarction in a Large Employed Popula-
tion, JAMA, 175:139, 1961.

Chiang, B. N. L. V. Perlman, M. Fulton, L. D.
Ostrander and F. H. Epstein: Predisposing Factors
in Sudden Cardiac Death in Tecumseh, Michigan:
A Prospective Study, CIRC., 41:31, 1970.

Short, D. and M. Stowers: Earliest Symptoms of
Coronary Heart Disease and Their Recognition,
BRIT. MED. J., 2 :387, 1972.

Mason, R. E., I. Likar, R, O. Biern, and R. S. Ross:
Multiple-Lead Exercise Blectrocardiography: Ex-
perience in 107 Normal Subjects and 67 Patients
with Angina Pectoris, and Comparison with Coronary
Arteriography in 84 Patients, CIRC., 36 :517, 1967.
Demany, M. A, A. Tambe and H, A. Zimmerman:
Correlation Between Coronary Arteriography and
the Postexercise Electrocardiogram, AM. J. CAR-
DIOL., 19 :526, 1967.

. Cohn, P. F., P. S, Vokonas, M. V. Herman and R.

Gorlin: Postexercise Electrocardiogram in Patients
with Abnormal Resting Electrocardiograms, CIRC.,
43 :648, 1971.

Lewis, W. J. and W. J. Wilson: Correlation of Coro-
nary Arteriograms with Master's Test and Tread-
mill Test, ROCKY MT. MED, J., 68:30, 1971.

Gordon, T. and W. B. Kannel: Premature Mortality
from Coronary Heart Disease, JAMA, 215-1617,
1971.

Lategola, M. 'T. and P. J. Layne: Establishment of
Normal ECG Amplitude/Frequency Values: A Po-
tential Basis for Early Detection of Coronary Heart
Disease in Aviation Personnel; BIOMEDIZINISCHE
TECHNIK, (In Publication).

. Scher, A. M. and A. C. Young: Frequency Analysis

of the Electrocardiogram, CIRC. RES., 8:344, 1960.

Langner, P. H. and D, B. Geselowitz: Characteristics
of the Frequency Spectrum in the Normal Electro-
cardiogram and in Subjects Following Myocardial
Infarction, CIRC. RES., 8:577, 1960.

Cady, L. D., M. A. Woodbury, J. L. Tick and M. M.
Gertler: A Method for Electrocardiogram Wave-
Pattern Estimation-Example: Left Ventricular Hy-
pertrophy, CIRC. RES, 9:1078, 1961.

Franke, E. K., J. R. Braunstein and D, Z. Zellner:
Study of High-Frequency Components in Blectro-
cardiogram by Power Spectrum Analysis, CIRC.
RES., 10:870, 1962.



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23



Tasie 15. =Normal Group. H=Harmonic. Max.~Maximum Amplitude Value. Min.=Minimum Amplitude
Value, £=Fundamental of 10 Hz for harmonic #1. %=Per Cent Amplitude Values.

(N)
SR-CM5-QRS —(%)
Max. Min. rit Max. Min. H Max. Min. H Max. Min.

fl 101] 6441 7.151 74152] 2419 | 2151
2 102] .392 | 2152 []152] 2445 | 6115
2 1103] .365 | 2114

reed +385 He
5 . .
6 106 2388 2115,
3 A whee 3} °
9 1.09 Bae 0155

10 110} 2392 | .133
1 M12] 432 | .157
12 212] 6432 | 0124
i 123} .412 | .191
15
16
17
18
19

BEETS ESSSSESSASRLGGESS BYR VBSLB

16


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(N)



normal group. Details of the total multi-session
screening process for the selection of the normal
subjects have been reported previously.** Age,
height and weight for each normal male are
compiled in Table 2.

Taste 2. S.E.=Standard Error

VITAL STATISTICS

NORMAL MALES

SUBJECT AGE REIOHT WEIGHT

NUMBER, (YEARS) (INCHES) (POUNDS)
i 2 ] Bf | RS
8 30 65.0 138.0
9 27 25, 164.0
2 3 he irs
33 3 68:75 163.0
5 22 10.75 16120
7 24 He 16270
19 30 225 158.25
ai 29 68:25 143.75
22 27 74.0 189.0
2h 25 6.0 157.5
5 % ae 156.0
34 28 B35 1610
36 26 72.5 175.0
Fi 22 7h 190.0
3 25 73.0 150.0
: a | Be | BB
4B 28 68.5 175.0
52 26 70.0 12815
52 29 66:0 13850
5 26 68.75 ilig'o
5 2h 70.75 168.5
z : me | HES
60 26 745 i72:0
62 68:75 16120
wean-26.87  Mean=70,08 Mean=160.57

S.E.= 0.44 S,E.= 0.44 S.E.= 3.19

B, Selection of CHD Subjects. Thirty male
CHD subjects were selected for this study. Em-
ployees of the FAA Aeronautical Center, Okla-
homa City, comprised the sole source of volunteer
candidates for the CHD group. The criteria for
selection were medically documented histories of
angina pectoris and/or myocardial infarction
and/or positive angiocardiography. All selec-
tions for this group were critically reviewed by
CAMI staff physicians. The selection criteria
for each of the selected CHD subjects are com-
piled in Table 3. In this group, firm medical
documentation existed for myocardial infarction
in 28, for angina pectoris in 15, and for positive
angiocardiography in 6 of these 30 CHD sub-
jects. Angiocardiography had not been run on
24 of this group. Age, height and weight for
each CHD male are compiled in Table 4.

C. Data Acquisition and Analysis. Table 5
presents the general data-acquisition procedures
for the overall experimental protocol of this
study. Both the normal and CHD groups were
scheduled through this total protocol. This

TasLe 3. MI=Myocardial Infarction. AP=Angina
Pectoris. PA=Positive Angiocardiogram of 250%
luminal atherosclerotic obstruction of one or more
major coronary arteries. X=Medically documented
history in the specified diagnostic category.

SELE a
CHD MALES
SUBJECT
NUMBER MI AP PA
6 x
& x x
5 x x
67 x x
6B x
& x
TO x
na x x
B x x
Bot
x
6 x *
7 x
R x
x x
81
82 x * *
83 x
x
85 x x
86 x
87 x x
88 x
90 x
91 x
9 x
953 x
x
36 x x *
37 x x
‘Sum=23 ‘Sume15 Sun=6
Taste 4. §.E.=Standard Error.
VITAL STATISTICS
CHD MALES
SUBJECT AGE HEIGHT WEIGHT
NUMBER (YEARS) (INCHES) (Pounps)
6: 51 5 177.0
a 51 a: 5 180.5,
65 8 8 167.0
M4 A 5 157.0
Pi 157.25
& 179.0
z : ie
Tr is 163:0
i z 3
7 5 133.5
7 z 17.0
RB 1 250.0
60 192.0
81 53 168.0
82 39 201.0
8: 39 171.75
8 55 147.0
8 z 180:0
Bi 217.0
& 58 2162.0
31 20910
90 5 i7i0
91 & 160:0
3: 43 201.75
9 55 aT.
9 2 176:0
3 3 196.0
37 50 27335
Mean=51.30 Mean#68.13 Mean=174,83
S.E.= 1.23 S.E.= 0,39 S.E= 4.49

present report deals only with evaluation of the
data obtained from a discrete unitary portion of
this total protocol focused directly on the screen-
ing discernment of the normal versus CHD



Taste 1.

SELECTION CRITERIA FOR CARDIOVASCULAR NORMALITY

PARAMETER

CRITERION

REMARKS.

1) Age
2) Smoking (tobacco)

3) Framingham Relative
Weight Index (FRWI)

4

Blood Pressure

5) Heart Rate
6) Vital Capacity

7) Standard 12-Lead
Clinical ECG

8) Physical Exam

9) CHD Family History

10) Cholesterol
21) Glucose

12) Uric Acid

13) Total Calcium

14) Sodium

15) Phosphorus

16) Potassium

17) Chlorides

18) Alk, Phosphatase
19) Total Bilirubin
20) Total Protein
21) Albumin

22) Globulin

23) a/a Ratio

24) scor

25) LDH

26) Creatinine

27) BUN

28) Hemoglobin

29) Hematocrit

30) RBC

31) wee

20-30 years inclusive
Never smoked

Never exceeded 110.0%

© 140/88 mm He (52)

100 beats/minute (52)
2 95.0% of age/neight
Standards Bay

Within normal limits (55)

Standard medical criteria

No CHD present in self, and
siblings and parents under
50 years of age.

= 2ho mg % (63)

75-120 mg %

2.67.2 mg &

8.8-11.0 mg %

135-150 mEq/L
2.1-4.7 mg %
3.0-5.0 mEq/L
94-100 mEq/L
0.6-2.5 BLU
0.1-1.2 mg £
5.9-8.0 gm %
3.3-5.2 gm %
1.5-3.8 gm %
2.1-2.5

11-52 SFU
280-770 BBU
0.31.8 mg %
7.0-25.0 mg %
12.5-17.2 gm %
37.0-51.0 %
4.35.9 x 10°/mm3
4.79.7 x 103/mm3

Age on day of study entry,
Teen-age smoking (1 month) discounted.
An FRWI of 100,0% indicates that the
weight of the individual is equal to
the median weight of the FHS males of
his same height at the 1950 inception
of the PHS (51). An FRWI of 2 120.0%
indicates frank obesity (51).
Determined using standard medical
Sphygmomanometry (53), after a minimum
of 15 minutes supine rest.

Determined. from a 60-second ECG recorded
after a minimum of 15 minutes supine rest,

Best of two trials in seated upright
position,

Data obtained in accordance with the
1967 AHA standards (56). All records
were read double-blind by CAMI staff
physicians.

Examinations conducted by CAMI staff
physicians.

Data obtained from non-medical interview,

Fasting blood sample
Fasting blood sample

Fasting blood sample

Pasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Pasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Pasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample
Fasting blood sample

Fasting blood sample


Taste 16, N=Normal Group.
Value, f=Fundamental of 10 Hz for harmonic #1.

H=Harmonic,

Max.=Maximum Amplitude Value.

(N

)

Min,=Minimum Amplitude
%=Per Cent Amplitude Values.

SR-CMs5-S179 (%)

H_ Max. Min. al Max. Min. H Max. Min. H Max. Min.
£1 | 27.376 | 5.134 7385 | .103 Jf101] .250] .049 f]151] .316] .097
2 | 12.550 | 5.562 2 «356 | .087 ||102] .261 087 152] .331| .065
3 | 8.4h2 | 3.392 |] 53] 385 | :092 |1103] .267] .078 1/153) .442) .080
% | 10.891 | 2.748 }] 54] 1951 | .117 |]108] .265] .077 1/254) 427] .070
5 | 5.810 | 1.547 |] 55| 498 | 2081 |]105] .271| .076 [1155] .472) .083
6} 3.878} 1.623 |] 56} .361 | .070 |/106) . a 3060 |]156) £331] .070
i 32093| .998 |] 57] .366 | .070 |]/107) . 2092 1157] . +060
2.097 338 58| 2391 | .087 |/108) .487] .057 |/158] .490| .o92
9| 2.525] - 59 | 385 | 2076 |]109| .353] -076 |]159} .342] .076
10} 2.017] 2151 |] 60] .324 | 113 |]120! .312] .087 |]260) .353) .092
1l 1.993 2226 || 62] 2431 | .065 |/112 25H 076 |/161| .513 278
12| 5.866] .209 |] 62] . 2129 |J112] .341 | .086 |/162} .409] . 3
13| 5.694] °787 |] 63] .321 | .065 |/113] .261 | .060 163 302 .071
ih | 22420] [579 |] 64 | 2345 | 2060 }]114] .520] .076 }]164) .383) .043
15 | 1.652] .%65 |) 65] .302 115} .372] .049 |]165] .673] .057
16 | 1.415] .453 |} 66] .338 116] 2427] 1076 |]166] 343] 2060
17 | 1.316] .350 |} 67] .334 117] .372| .o91 {}167| .308) .076
18 | 1.203| .259 |] 68) .359 118] 1282] .052 ||168} .584} .076
19} 1.172] 138 }] 69} .333 119] .255] .081 |/169 “338 2069
20] 1.461] 2138 |] 70] -333 120) «320 2054 {170} 483] .085
21) 3.741] .32 71] .43 1a1] 450] .069 }1171] .461) .070
22] 1.305] .372 |] 72] .338 122| 1294] .081 |]172| .261| .060
2 856] .081 || 73) .278 123] .770| .065 1}173] 302] .092
2 769 | .060 || 74) .327 12h] 1394] .087 |]174| 454) .076
25] .837} .125 || 75] .269 125| .309} .052 [1/175] .297] .068
26 «772 | .065 || 76] .327 126| [290] .076 |]176| .391| .076
27| :829] .103 |] 77] .334 127| 2435 | .091 }]177| 327] .052
28{ .725| .149 || 78] .2! 128] 1316] .060 |/178] .357| .076
29} 2.649] .219 |] 79] .40: 129] 1372] .092 |]179| .346) .082
30] 691] .200 || 80 3 130 +309 +054 1/180) ee 2092
31] .706} .119 |} 81] .342 131| 1294] .070 }/181] .346| .076
32 +833 +113 || 82 | - 309 132] 1271] .087 1/182] .387| .092
3 : 173 83| .28) 133] 1275] .081 |/183] .342] .070
3 2549 | 61 84} 1275 134] [278] .080 |/184| .265| .087
33 2560] .146 || 85] .282 135] .361| .060 ]}185] .383| .065
36 ~851 | .108 |] 86] .305 136] 323} .081 |/186| .427| .077
37] 1.124] .201 Hi 128 137] .989 | .060 187) 2331] .049
38] .868) .174 . 138] .267| .065 |]188} .327] .057
2 +511 | .130 {| 89] .362 139 287 | .081 }]189] .297} .078
0 ~844} .103 |] 90] .282 iho] 2409 | .065 |]190} .353] .076
4 +488) .092 |] 91) .282 141] .576| .081 }}192 33 2076
42] .473] 076 |] 92] .287 142] £335] .060 |]192] .282| .065
43) 248k! .076 || 93] 323 143] .387| .087 |]193] .361] .057
4h | luer] .076 1] 94] .255 14h] 1261] .070 ]]194) .268| .072
45]  .464] .081 |] 95) .282 145] 1352] .076 ]1195| .276] .057
46] 2858] .139 |] 96 +293 146] 1282] .078 11196] .324) .065
az} abs). 330 97] 34 y47| 1282] .065 }]197]) .265) .o74
z cert 087 98] .26! 18 “He 2978 ey 262 058
. 1 9} .298 | .0 149 . . . .
50] 353] .108 10 | 1261 150] .265] .069 |}200] .379] .062

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normal subjects was a positive angiocardiogram
of >50% luminal atherosclerotic obstruction of
one or more major coronary arteries. All de-
grees of positive ST segment depression listed
in Table 22 include a minimum duration of 0.08
seconds. The IM values ranged from 0.07 to
0.81.

Table 23 presents the Se, Sp and IM ratings
for all possible combinations of the four ECG
segments with separation Criteria I and II as
utilized in our present study. In each cell of
this Table, the upper number represents the Se,
the middle number the Sp and the lower number
(in parentheses) the IM ratings respectively for
that particular cell. A total of 45 IM ratings
are compiled in Table 23. Of these ratings, the
ST,./I combination provided the lowest value of
0.46. The average IM rating of the seventeen
clinical studies presented in Table 22 was 0.49.
The highest IM rating of the seventeen clinical
studies in Table 22 was 0.81. In Table 23, only
4 of the IM values are less than 0.81; 9 of them
have values from 0.83 to 0.97; and the remaining
32 have a common value of 1.00.

Iv.

The IM ratings in Table 23 are based on A/F
data from a maximum of one whole electro-
cardiac cycle per person recorded from one ECG
lead at supine rest. Since these ratings compare
quite well with those of’ contemporary exercise
ECG tests, as shown in Table 22, the former
appear to reflect a potential capability for im-
proved screening detection of CHD. However
promising, these initial results must be consid-
ered as tentative because of the retrospective
design of this study. The separation Criteria (I
and II) utilized in this study were chosen arbi-
trarily and tested for their potential capabilities
of screening discernment of two different but
known population segments. As is the case for
results from any initial retrospective study, such
results are considered to be scientifically vali-
dated only if corroborated by a prospective
double-blind test. In the context of this study,
this would simply consist of applying our screen-
ing procedure to a suitable number of male test
subjects whos enormal or CHD status is unknown
to us. Our data-based selection of the normal or
CHD status of each subject would be compared
subsequently to that determined by a concensus

Discussion

25

board of cardiologists. For the purpose of cal-
culating the appropriate IM for this double-blind
validation procedure, the cardiological diagnosis
(normal or CHD) will be considered as the
definitive standard against which the correct-
incorrect selection by the A/F method will be
judged.

Because of the initial, retrospective nature of
the present study, it would appear quite un-
reasonable to expect that the IM rating obtained
from the double-blind procedure would closely
approximate the major trend of the 45 IM values
in Table 23. However, it is quite reasonable to
expect that, in order for the A/F method to be
considered as a useful improvement for screening
detection of CHD, its double-blind IM rating
should again compare favorably with those of
accepted clinical methods as exemplified in Table
92, Preliminary plans for a double-blind vali-
dation test have been formulated and are tenta-
tively projected for activation in the near future.

For an initial, retrospective type study, the
strong showing of the IM values in Table 23
exceeded conservative expectations by some de-
gree. This initial strength of discernment based
on a supine rest, single-lead ECG recording was
surprising when considered in the light of a
coincidental observation. A resting, standard
12-lead clinical ECG was recorded on all normal
and CHD subjects as an integral part of the
overall screening procedure. Using accepted
medical standards as the basis of judgment,’ the
12-lead clinical ECGs of 17 of the 30 CHD sub-
jects were interpreted by CAMI staff physicians
as falling “within normal limits.” This would
seem to provide evidence in addition to our pre-
liminary observations concerning the possibility
of masking and/or absence of useful A/F infor-
mation within the integral ECG signal.*

The initial degree of discernment shown in
Table 23 is additionally remarkable in view of
the frequency resolution of only 10 Hz used in
this study. Taking into account the approximate
shift in real-time frequencies which resulted
from the segment time-normalization process, a
maximum of about 40 harmonics for the STw
and a minimum of about 5 for the QRS segments
respectively represent the real-time frequency
band of about DC to 100 Hz. A previous study
has estimated that approximately 95% of the
real-time A/F power spectrum lies below 100
Hz. The discernment reflected in Table 23 is



Technical Report Documentation Page

1. Report No. 2. Goverament Accession No.

FAA-AM-74- 6

3. Recipient's Cotalog No.

4. Title and Subtitle

AMPLITUDE/ FREQUENCY DIFFERENCES IN A SUPINE
RESTING SINGLE-LEAD ELECTROCARDIOGRAM OF
NORMAL VERSUS CORONARY HEART DISEASED MALES

5, Report Date

May 1974

7, Author's)
Michael T. Lategola, Ph.D. and Peter J. Layne

&. Performing Organization Code

=
8. Performing Organization Report No.

9. Performing Organization Name ond Address
FAA Civil Aeromedical Institute
P. O. Box 25082

Oklahoma City, Oklahoma 73125

10. Work Unit No. (TRAIS)

TT. Contract or Grant No.

12. Sponsoring Agency Name and Address
Office of Aviation Medicine
Federal Aviation Administration
800 Independence Avenue, S.W.
Washington, D. C. 20591

13. Type of Report and Period Covered

OAM Report

14. Sponsoring Agency Code

15. Supplementary Notes

Work was performed under Task AM-A-74-PHY-66

16, Abstract

A resting "normal" ECG can coexist with known angina pectoris, positive angio-

cardiography and previous myocardial infarction.
tests, a false positive/false negative total error of 10% is not unusual,

Research aimed at improved screening detection of CHD evaluated amplitude/frequency
analysis of high fidelity ECG recordings.
mented CHD were selected.

recording. Two bipolar leads were recorded during supine rest.

An analysis system provided for digital conversion, division of whole electrocardiac
cycles into four defined segments, time-normalization of each segment, and ampli-
tude/frequency analysis. Analyses provided a digital plot for each segment and for

each 30-subject average.

The results from the CM, lead recorded at supine rest are presented,
the normal versus CHD groups across the 30-subject average amplitude values for

each of 200 harmonics per segment revealed significant differences (P < 0.05) at
Two criteria, based only on the maximum and minimum

amplitude values for each of the 200 harmonics, succeeded in individual screening
separation of the normal versus CHD males.
those of seventeen clinical studies using exercise electrocardiography.

most of the 200 harmonics.

In contemporary exercise ECG

Thirty normal males and 30 with docu-
Analog ECGs were obtained using electromagnetic tape

The results compare favorably with

Comparison of

17, Key Words

Coronary heart disease, Early detection,
Aeromedical screening, Electrocardio-
graphy, Amplitude/frequency analysis

18, Distribution Statement

Availability is unlimited.

released to the National Technical Informa-
tion Service, Springfield, Virginia 22151,

for sale to the public.

Document may be

19. Security Classil. (of this report)

Unclassified

20. Security Classif. (of this page)

Unclassified 28

21- No. of Pages

22, Price

$3.00

Form DOT F 1700.7 (8-72)

Reproduction of completed page authorized



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states. Evaluation of possible inter-correlations
of the remaining data with those presented here
have been planned as a subsequent effort. The
data evaluated in this report emanated from the
segments of one whole electrocardiac cycle per
subject obtained from one bipolar ECG lead
(CM,)* during the two-minute supine test re-
cording of data acquisition procedure 2C (Table
5). The recording of the 2C portion of the data
protocol was preceded by at least 15 minutes of
supine rest. Vigorous skin preparation, low-
resistance ECG paste® and silver/silver chloride
electrodes® were utilized exclusively for all bi-
polar lead recording.

Two sets of equipment were required to carry
out this study. The set used for analog ECG
data acquisition was located at the CAMI in
Oklahoma City. The set used for A/F analysis
was located at the NASA-White Sands Test
Facility (WSTF) in Las Cruces, Nev Mexico.
At task onset, the specific equipment and man-
power for the A/F analysis portion of this study
were not available in-house at the FAA Aero-
nautical Center. End-to-end calibration of both

sets of equipment was a mandatory prerequisite
to data acquisition and analysis. Detailed de-
scriptions of all specific equipment and proce-
dures for calibration, data acquisition and data
analysis have been reported previously.”

The analog ECG recordings of the bipolar
lead were obtained using a wide-band high fidel-
ity electromagnetic tape recording system. At
the constant recording/playback tape speed of
15 inches per second used in this study, this
system has a verified total flat frequency range
of DC to 5000 cycles per second (Hz). Calibra-
tion of this system included a range of +5 milli-
volts DC and a frequency range of DC to 2000
Hz. The common-mode rejection ratio for 60 Hz
noise was 120 decibels (dB). Instrumentation
grade electromagnetic tape was used exclusively
for the analog ECG data acquisition. All elec-
tromagnetic tape recordings were time and voice
coded in parallel with a written time and event
log for the purpose of facilitating subsequent
identification and isolation of any specific portion
to be analyzed.

Taste 5.

DATA ACQUISITION PROTOCOL

CONDITION PROCEDURE.

REMARKS

1) Supine Rest

Standard 12-lead Clinical ECG

All ECG signals were recorded
using a wide-band high fidelity
electromagnetic tape recording
system (57).

2) Supine Rest-
CMs and O
bipolar leads

recorded
simultaneously,

3) Seated Upright

a) Respiratory inspiration
held for 10 seconds.

b) Respiratory end-expiration
held for 10 seconds.

¢) Sequentially: two minutes of
quiet horizontal rest; two
minutes of 45°, feet-down
tilt; two minutes of
horizontal recovery.

a) Blood pressure measurement
after 15 minutes of rest.

b

Continuous simultaneous
recording of CM, and 0 leads
and oxygen uptake during:
five minutes of quiet rest;
three minutes of 50 RPM,
25-watt bicycle ergometry;
six minutes of 50 RPM,
50-watt bicycle ergometry
(blood pressure measurement
at the fourth minute); and
eight minutes of resting
recovery.

EC@ recording system as cited
above,

Standard medical method of
sphygmomanometry (53).

ECG recording system as cited above.

Oxygen uptake measured by a Webb
Meter (58).

Oxygen uptake at the 50-watt
ergometry load approximates that
of the Master two-step test (59).


Taste 21. CHD=Coronary Heart Disease Group. H=Harmonic. Max.=Maximum Amplitude Value. Min.=
Minimum Amplitude Value. f=Fundamental of 10 Hz for harmonic #1. %=Per Cent Amplitude Values,

(CHD)

SR-CM5-STw — (%)
5STw (%

Max. Min. H Max. Min. H Max. Min. H Max. Min.
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7% 2379 | 1078
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81 "376 | 1080
82 3! 078
83 +36! 101
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8 £376 | 2075
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89 +360 | .082
90 £352 | 1076

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95 +352 +092
37 1385 | (3
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100 2376 | :068

22


Thompson, N. P.: Fourier Analysis of the Electro-

cardiographic Function, AM. J. MED, ELECTRON.,

1:299, 1962.

Dworetzky, L. H., R. I. Bristow, J. M. Endres, G. J.
Haupt and N. ©. Birkhead: Fourier Analysis of
Exercise Electrocardiograms, Chapter 10 in Measure-
ment in Exercise Electrocardiography, C. C. Thomas,
Springfield, Illinois, 1969,

Langner, P. H., D. B. Geselowitz and 8, A. Briller:
Wide Band Recording of the Electrocardiogram and
Coronary Heart Disease, AM. HEART J., 86:308,
1973,

Golden, D, P., Jr, R. A. Wolthius and G. W. Hoffler:
A Spectral Analysis of the Normal Resting Blectro-
cardiogram, IEEEE TRANS. BIOMED. ENGR.,
20 :366, 1973.

W. B. and T. R. Dawber: Contributers to Coronary
Risk Implications for Prevention and Public Health:
The Framingham Study, HEART AND LUNG,
‘1:797, 1972.

. Lategola, M. T. and P. J, Layne: A Method for
Amplitude/Frequency Analysis of High Fidelity

51,

2

54,

34187

28

57.

59.

Electromagnetic Tape Recordings of the Electro-
cardiogram, FAA Office of Aviation Medicine Report
(In Publication).

Bordley, J., C. A. R, Connor, W. F. Hamilton, W. J.
Kerr and ©. J. Wiggers: Recommendations for Blood
Pressure Determinations by Sphygmomanometers,
CIRC., 4:503, 1951.

Webb, P. and S. J. Troutman, Jr.: An Instrument
for Continuous Measurement of Oxygen Consump-
tion, J. APPL. PHYSIOL., 28 :867, 1970.

Ford, A. B. and H. K. Hellerstein: Energy Cost of
the Master Two-Step Test, JAMA, 164 :1868, 1957.
Blackburn, H., H. L. Taylor, N, Okomoto, P. Rauta-
harju, P. Mitchell and A. C. Kerkhof: Standardiza-
tion of the Exercise Electrocardiogram: A Systematic
Comparison of Chest Lead Configuration Employed
for Monitoring During Exercise, Chap. 9, Physical
Activity and the Heart, C. C. Thomas, Springfield,
Mlinois, 1967.

. Guide for Aviation Medical Examiners, Office of

Aviation Medicine, Federal Aviation Administration,
Department of Transportation, 1970.




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Taste 14. N=Normal Group. H=Harmonic. Max.=Maximum Amplitude Value. Min.=Minimum Amplitude
Value. f=Fundamental of 10 Hz for harmonic #1. %—=Per Cent Amplitude Values.

(N)
SR-CM5-PQ = (%)
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33 1.096] .190 || 73] 1.737 | .109 |]123 +833 091 {]173] .283] .088
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27 | 1.963] .185 |] 77] 1.050] .129 |]127] .280] .089 |]177| .283] .09!
28 | 4.757) 22 78| 1.331 | .134 |/128] 1286] .095 {]178] 1292] .098
29 | 1.774] .216 || 79] 372] .129 |J120] .305] .069 179) .270) .099
30 | 1.318 “173 Bo] cugu] 2122 |1130| 1283] .076 [180] .292] .099
31 | 2.329] . 81) +323] -128 [/132) 40 2085 {181} .298] .103
32 | 7.731 | .224 || 82] 2479] 2123 |]132] .295] .084 [1182] .350] .
33 | 5.477 | 2174 |] 83] 1.760] 2143 |/133] 283] .094 1/183] .292] .085
6.765 | .202 |] 84] 939] 104 Ha 292 | .O79 184] .273] .109
35 | 2.600] .242 1] 85] . 2098 1/135] .601] . 185]. oe
36 | 5.893| .185 |] 86] .280] .085 |/136] .308] .105 |/186] . .
z 1.093] .2 87] .622] .094 |/137| .295] .078 }]187) .320) .081
«870 | .224 |] 88} 375] .078 |/138] .295] .109 1188) .295) .
FA 1.264] .157 |] 89] .270] .109 {/139] .324] . 289} .295] .083
0 | 3.976] .193 |] 90] .316| .098 |/140} .283] .098 1190] .327] .099
ay +288 all 91] .314] .098 ]]141] .295] .095 1/191] .308) .099
42 | .528} .153 |] 92] .295| .065 |}]142] .286] .100 |f192] .298] .103
8 4.764 | 4263 |] 93) .873| .084 |/143] .333] .098' 11193) .298] .089
2 1.058 | «173 I} 9 +830 974 ua 283 2098 Fe +235 08k
. . 95| 895]. . . . .
wey. 143 1196) 472] .098 |]146] . “ 29 308 084

15



ACKNOWLEDGMENTS

The authors sincerely acknowledge: (1) Drs. Charles M. Brake and
Samuel F. Flynn of AAC-160 for their substantial contributions in the medi-
cal screening, clinical ECG evaluation and medico-legal coverage aspects of
this study; (2) Kenneth B. Gilbreath, Jesse Jones, Kenneth R. Haynes,
Albert Duran and David L. Pippin of the NASA-White Sands Test Facility
for their respective contributions to the successful completion of the data
analysis portion of this study; (3) Peggy J. Lyne and Paula M. Grape for
their excellent technical assistance; (4) Richard F, Chandler, AAC-119, for
his constructive evaluations during several phases of this study; and (5)
Everett Bates of MarDen Enterprises for his early contributions to the
methodological portion of this study.



based therefore on a very small portion of the
total potential information available in real-time
A/F analyses using finer frequency resolution.
Evidence exists in the A/F data of this present
study as well as previous preliminary probes‘
for the possible presence of distinct normal and
CHD “frequency signatures” which may be vul-
nerable to on-line band pass techniques.

On contingency of successful validation of the
present results by a double-blind test, long range
parallel efforts have been tentatively planned for
pursuit of the “frequency signature” concept and

for the conversion of hardware facets of the
prototype A/F method to validated software
computer equivalents. Software analyses using
modern computer techniques would be more uni-
versally applicable and amenable to mass data
processing should the use of this method ever be
called upon for the screening detection of CHD
in the airman population. The useful degree, if
any, to which the A/F and/or on-line band pass
methods succeed should be reflected in a com-
mensurate enhancement of aviation safety and
cardiovascular health maintenance.

REFERENCES

H

. Siegel, P. V.: Congressional Record: Subcommittee
of the Committee on Appropriations, House of Rep-
resentatives, Part 2, Department of Transportation
and Other Agencies, p. 1087, April 29, 1971.

Aeromedical Certification Statistical Handbook, Fed-
eral Aviation Administration, Department of ‘Trans-
portation, 1972.

3, Lategola, M. T.: The Use of Simple Indicators for
Detecting Potential Coronary Heart Disease Sus-
ceptibility in the Air Traffic Controller Population.
FAA Office of Aviation Medicine Report No. FAA~
AM-72-20, 1972.

Lategola, M. T.: The Use of Simple Indicators for
Detecting Potential Coronary Heart Disease Sus-
ceptibility in the Third-Class Airman Population.
FAA Office of Aviation Medicine Report No. FAA-
AM-72-26, 1972,

. Friedberg, ©. K.: Diseases of the Heart, W. B.

Saunders, Philadelphia and London, 1966,

6. Martin, C. M. and D. R. McConahay: Maximal
Treadmill Exercise Electrocardiography: Correla-
tions with Coronary Arteriography and Cardiac
Hemodynamics, CIRC., 46:956, 1972.

7. Dwyer, E. M. L. Wiener and J. W. Cox: Angina
Pectoris in Patients with Normal and Abnormal
Coronary Arteriograms, AM. J. CARDIOL,, 23:639,
1969,

8. Neil, W. A. M. P. Judkins, D. 8. Dhindra, J. Met-
calfe, D, G. Kassebaum and F. E. Kloster: Clinically
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by Demonstrable Coronary Artery Disease, AM. J.
CARDIOL., 29:171, 1972,

9, Helfant, R. H., J. S. Forrester, J. R. Hampton,
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Heart Disease: Differential Hemodynamic, Metabolic
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Cd

»

ey

and Without Angina Pectoris During Atrial Pacing,
CIRC., 42:601, 1970.

10. Kemp, H. G., W. Elliott and R. Gorlin: The Anginal
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11, Sheffield, L. T., J. H. Holt, F, M. Lester, D. V. Conroy
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Electrocardiogram, CIRC., 40:985, 1969.

12. Martinez-Rios, M. A., B. C. Bruto DaCosta, FP. A.
Cecena-Seldner and G. G. Gensini: Normal Electro-
cardiogram in the Presente of Severe Coronary
Disease, AM. J. CARDIOL, 25 :320, 1970.

18. Campeau, L., M. G. Bourassa, M. A. Bois, J. Saltiel,
J. Lesperance, O. Rico, T. L. Delcan and M. Telluria:
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graphy, CANAD. MED. ASSOC. J., 99:1063, 1968,

14. Likoff, W., H. Kasparian, B. L, Segal, P, Novak and
J. §. Lehman: Clinical Correlation of Coronary
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15. Ascoop, C. A., M. L. Simoons, W. G. Egmond and
A. V. G. Bruschke: Exercise Test, History and
Serum Lipid Levels in Patients with Chest Pain and
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1971.

16. Saltups, A, B. D. McCallister, F. J. Hallermann,
R. B. Wallace, R. E. Smith and R. L, Frye: Left
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nary Artery Disease and in Normal Subjects, AM.
J. MED., 50:8, 1971.

17. McConahay, D. R., B. D. McCallister and R. BE.
Smith: Postexercise Electrocardiography: Correla-
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1971.

18. Likoff, W., H. Kasparian, B. L. Segal, H. Forman
and P. Kovack: Coronary Arteriography: Correla-




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