A decision tree – based method for the differential diagnosis of Aortic Stenosis from Mitral Regurgitation using heart sounds
© Pavlopoulos et al; licensee BioMed Central Ltd. 2004
Received: 20 February 2004
Accepted: 29 June 2004
Published: 29 June 2004
New technologies like echocardiography, color Doppler, CT, and MRI provide more direct and accurate evidence of heart disease than heart auscultation. However, these modalities are costly, large in size and operationally complex and therefore are not suitable for use in rural areas, in homecare and generally in primary healthcare set-ups. Furthermore the majority of internal medicine and cardiology training programs underestimate the value of cardiac auscultation and junior clinicians are not adequately trained in this field. Therefore efficient decision support systems would be very useful for supporting clinicians to make better heart sound diagnosis. In this study a rule-based method, based on decision trees, has been developed for differential diagnosis between "clear" Aortic Stenosis (AS) and "clear" Mitral Regurgitation (MR) using heart sounds.
For the purposes of our experiment we used a collection of 84 heart sound signals including 41 heart sound signals with "clear" AS systolic murmur and 43 with "clear" MR systolic murmur. Signals were initially preprocessed to detect 1st and 2nd heart sounds. Next a total of 100 features were determined for every heart sound signal and relevance to the differentiation between AS and MR was estimated. The performance of fully expanded decision tree classifiers and Pruned decision tree classifiers were studied based on various training and test datasets. Similarly, pruned decision tree classifiers were used to examine their differentiation capabilities. In order to build a generalized decision support system for heart sound diagnosis, we have divided the problem into sub problems, dealing with either one morphological characteristic of the heart-sound waveform or with difficult to distinguish cases.
Relevance analysis on the different heart sound features demonstrated that the most relevant features are the frequency features and the morphological features that describe S1, S2 and the systolic murmur. The results are compatible with the physical understanding of the problem since AS and MR systolic murmurs have different frequency contents and different waveform shapes. On the contrary, in the diastolic phase there is no murmur in both diseases which results in the fact that the diastolic phase signals cannot contribute to the differentiation between AS and MR.
We used a fully expanded decision tree classifier with a training set of 34 records and a test set of 50 records which resulted in a classification accuracy (total corrects/total tested) of 90% (45 correct/50 total records). Furthermore, the method proved to correctly classify both AS and MR cases since the partial AS and MR accuracies were 91.6% and 88.5% respectively. Similar accuracy was achieved using decision trees with a fraction of the 100 features (the most relevant). Pruned Differentiation decision trees did not significantly change the classification accuracy of the decision trees both in terms of partial classification and overall classification as well.
Present work has indicated that decision tree algorithms decision tree algorithms can be successfully used as a basis for a decision support system to assist young and inexperienced clinicians to make better heart sound diagnosis. Furthermore, Relevance Analysis can be used to determine a small critical subset, from the initial set of features, which contains most of the information required for the differentiation. Decision tree structures, if properly trained can increase their classification accuracy in new test data sets. The classification accuracy and the generalization capabilities of the Fully Expanded decision tree structures and the Pruned decision tree structures have not significant difference for this examined sub-problem. However, the generalization capabilities of the decision tree based methods were found to be satisfactory. Decision tree structures were tested on various training and test data set and the classification accuracy was found to be consistently high.
New technologies like Echocardiography, Color Doppler, CT, and MRI provide more direct and accurate evidence of heart disease than heart auscultation. However, these modalities are costly, large in size and operationally complex . Therefore these technologies are not suitable for use in rural areas, in homecare and generally in primary healthcare set-ups. Although heart sounds can provide low cost screening for pathologic conditions, internal medicine and cardiology training programs underestimate the value of cardiac auscultation and junior clinicians are not adequately trained in this field. The pool of skilled clinicians trained in the era before echocardiography continues to age, and the skills for cardiac auscultation is in danger to disappear . Therefore efficient decision support systems would be very useful for supporting clinicians to make better heart sound diagnosis, especially in rural areas, in homecare and in primary healthcare. Recent advances in Information Technology systems, in digital electronic stethoscopes, in acoustic signal processing and in pattern recognition methods have inspired the design of systems based on electronic stethoscopes and computers [3, 4]. In the last decade, many research activities were conducted concerning automated and semi-automated heart sound diagnosis, regarding it as a challenging and promising subject. Many researchers have conducted research on the segmentation of the heart sound into heart cycles [5–7], the discrimination of the first from the second heart sound , the analysis of the first, the second heart sound and the heart murmurs [9–12], and also on features extraction and classification of heart sounds and murmurs [14, 15]. These activities mainly focused on the morphological characteristics of the heart sound waveforms. On the contrary very few activities focused on the exploitation of heart sound patterns for the direct diagnosis of cardiac diseases. The research of Dr. Akay and co-workers in Coronary Artery Disease  is regarded as very important in this area. Another important research activity is by Hedben and Torry in the area of identification of Aortic Stenosis and Mitral Regurgitation . The reason for this focus on the morphological characteristics is the following: Cardiac auscultation and diagnosis is quite complicated depending not only on the heart sound, but also on the phase of the respiration cycle, the patient's position, the physical examination variables (such as sex, age, body weight, smoking condition, diastolic and systolic pressure), the patient's history, medication etc. The heart sound information alone is not adequate in most cases for heart disease diagnosis, so researchers generally focused on the identification and extraction of the morphological characteristics of the heart sound.
The algorithms which have been utilized for this purpose were based on: i) Auto Regressive and Auto Regressive Moving Average Spectral Methods [5, 11], ii) Power Spectral Density , iii) Trimmed Mean Spectrograms , iv) Sort Time Fourier Transform , v) Wavelet Transform [7, 9, 11], vi) Wigner-Ville distribution, and generally the ambiguous function . The classification algorithms were mainly based on: i) Discriminant analysis , ii) Nearest Neighbour , iii) Bayesian networks [20, 21], iv) Neural Networks [1, 8, 18] (backpropagation, radial basis function, multiplayer perceptron, self organizing map, probabilistic neural networks etc) and v) rule-based methods .
In this paper a rule-based method, based on decision trees, has been developed for differential diagnosis between the Aortic Stenosis (AS) and the Mitral Regurgitation (MR) using heart sounds. This is a very significant problem in cardiology since there is very often confusion between these two diseases. The correct discrimination between them is of critical importance for the determination of the appropriate treatment to be recommended. Previous research activities concerning these diseases were mainly focused on their clinical aspects, the assessment of their severity by spectral analysis of cardiac murmurs  and the time frequency representation of the systolic murmur they produce [9, 22]. The problem of differentiation between AS and MR has been investigated in  and . The method proposed in  was based on the different statistic values in the spectrogram of the systolic murmurs that these two diseases produce. The method proposed in  was based on frequency spectrum analysis and a filter bank envelope analysis of the first and the second heart sound. Our work aims to investigate whether decision tree-based classifier algorithms can be a trustworthy alternative for such heart sound diagnosis problems. For this purpose a number of different decision tree structures were implemented for the classification and differentiation of heart sound patterns produced by patients either with AS or with MR. We chose the decision trees as classification algorithm because the knowledge representation model that they produce is very similar to the differential diagnosis that the clinicians use. In other words this method does not work as a black box for the clinicians (i.e. in medical terms). On the contrary neural networks, genetic algorithms or generally algorithms that need a lot of iteration in order to converge to a solution are working as a black box for the clinicians. Using decision trees clinicians can trace back the model and either accept or reject the proposed suggestion. This capability increases the clinician confidence about the final diagnosis.
In particular, the first goal of this work was to evaluate the suitability of various decision tree structures for this important diagnostic problem. The evaluated structures included both Fully Expanded decision trees Structures and Pruned decision trees Structures. The second goal was to evaluate the diagnostic abilities of the investigated heart sound features for decision tree – based diagnosis. In both the above evaluations the generalization capabilities of the implemented decision tree structures were also examined. Generalization was a very important issue due to the difficulty and the tedious work of having adequate data for all possible data acquisition methods within the training data set. The third goal of this work was to suggest a way of selecting the most appropriate decision tree structures and heart sound features in order to provide the basis of an effective semi-automated diagnostic system.
Problem definition: differentiation between AS and MR murmurs
The first heart sound (S1, corresponding to the closure of the mitral and the tricuspid valve).
The systolic phase.
The second heart sound (S2, corresponding to the closure of the aortic and pulmonary valve).
The diastolic phase.
It can be concluded by the visual insplection of Figure 1 that the AS systolic murmur has very similar characteristics with the MR systolic murmur and therefore the differentiation between these two diseases is a difficult problem in heart sound diagnosis, especially for young inexperienced clinicians. All these facts define the problem of differentiation between the AS and the MR murmurs. In the following sections we propose a method based on time-frequency features and decision tree classifiers for solving this problem.
Preprocessing of heart sound data
Cardiac auscultation and diagnosis, as already mentioned, are quite complicated, depending not only on the heart sound but also on other factors. There is also a great variability at the quality of the heart sound affected by factors related to the acquisition method. Some important factors are: the type of stethoscope used, the sensor that the stethoscope has (i.e. microphone, piezoelectric film), the mode that the stethoscope was used (i.e. bell, diaphragm, extended), the way the stethoscope was pressed on the patients skin (firmly or loosely), the medication the patient used during the auscultation (i.e. vasodilators), the patient's position (i.e. supine position, standing, squatting), the auscultation areas (i.e. apex, lower left sternal border, pulmonic area, aortic area), the phase of patients' respiration cycle (inspiration, expiration), the filters used while acquiring the heart sound (i.e. anti-tremor filter, respiratory sound reduction, noise reduction). The variation of all these parameters leads to a large number of different heart sound acquisition methods. A heart sound diagnosis algorithm should take into account the variability of the acquisition method, and also be tested in heart sound signals from different sources and recorded with different acquisition methods. For this purpose we collected heart sound signals from different heart sound sources [31–39] and created a "global" heart sound database. The heart sound signals were collected from educational audiocassettes, audio CDs and CD ROMs and all cases were already diagnosed and related to a specific heart disease. For the purposes of the present experiment 41 heart sound signals with "clear" AS systolic murmur and 43 with ' "clear" MR systolic murmur were used.
Wavelet decomposition as described in  (with the only difference being that the 4th and 5th level detail was kept, i.e. frequencies from 34 to 138 Hz).
Calculation of the normalized average Shannon Energy .
A morphological transform action that amplifies the sharp peaks and attenuates the broad ones .
A method, similar to the one described in , that selects and recovers the peaks corresponding to S1 and S2 and rejects the others.
An algorithm that determines the boundaries of S1 and S2 in each heart cycle .
A method, similar to the one described in , that distinguishes S1 from S2
In a second phase, every transformed (processed in the first phase) heart sound signal was used to calculate the standard deviation of the duration of all the heart cycles it includes, the standard deviation of the S1 peak value of all its heart cycles, the standard deviation of the S2 peak value of all its heart cycles, and the heart rate. These were the first four scalar features (F1-F4) of the feature vector of the heart sound signal.
In a third phase, the rest of the features were extracted. For this purpose we calculated for each heart sound signal two mean signals for each of the four structural components of the heart cycle, namely two for the S1, two for the systolic phase, two for the S2 and two for the diastolic phase. The first of these mean signals focused on the frequency characteristics of the heart sound; it was calculated as the mean value of each component, after segmenting and extracting the heart cycle components, time warping them, and aligning them. The second mean signal focused on the morphological time characteristics of the heart sound; it was calculated as the mean value of the normalized average Shannon Energy Envelope of each component, after segmenting and extracting the heart cycles components, time warping them, and aligning them. Then the second S1 mean signal was divided into 8 equal parts. For each part we calculated the mean square value and this value was used as a feature in the corresponding heart sound vector. In this way we calculated 8 scalar features for S1 (F5-F12), and similarly we calculated 24 scalar features for the systolic period (F13-F36), 8 scalar features for S2 (F37-F44) and 48 scalar features for the diastolic period (F45-F92). The systolic and diastolic phase components of the above first mean signal were also passed from four bandpass filters: a) a 50–250 Hz filter giving its low frequency content, b) a 100–300 Hz filter giving its medium frequency content, c) a 150–350 Hz filter giving its medium-high frequency content and d) a 200–400 Hz filter giving its high frequency content. For each of these 8 outputs, the total energy was calculated and was used as a feature in the heart sound vector (F93-F100). With the above three phases of preprocessing every heart sound signal was transformed in a heart sound vector (pattern) with dimension 1 × 100.
Finally these preprocessed data feature vectors were stored in a database table. This table had 84 records, i.e. as many records as the available heart sound signals; each record describes the feature vector of a heart sound signal and has 102 fields. Each field corresponds to one feature of the feature vector or in other words to one attribute of the heart sound. One attribute for the pattern identification code named ID (used as the primary key of this database table), one attribute named hdisease for the characterization of the specific heart sound signal as MR or AS and 100 attributes for the above 100 heart sound features (F1-F100).
The decision tree-based method
Before constructing and using the decision tree Classifiers a Relevance Analysis  of the features was performed. Relevance Analysis aims to improve the classification efficiency by eliminating the less useful (for the classification) features and reducing the amount of input data to the classification stage. For example from the previous description of the database table attributes it is obvious that the pattern identification code (primary key) is irrelevant to the classification, therefore it should not be used by the classification algorithm.
In this work we used the value of the Uncertainty Coefficient [23–25] of each of the above 100 features to rank these features according to their relevance to the classifying (dependent variable) attribute which in our case is the hdisease attribute. In order to compute the Uncertainty Coefficients, the 100 numeric attributes were transformed into corresponding categorical ones. The algorithm that has been used for optimizing this transformation for the specific classification decision is described in . Then for each of these 100 categorical attributes, its Uncertainty Coefficient was calculated, as described in the following paragraphs.
Initially we have a set P of p data records (84 data records in our case). The classifying attribute (dependent variable) for this differential diagnosis problem has 2 possible discrete values: AS or MR, which define 2 corresponding subsets discrete classes Pi (i = 1, 2) of the above set P. If P contains pi records for each Pi (i = 1, 2), (p = p1 + p2) then the Information Entropy (IE) of the initial set P, which is a measure of its homogeneity concerning the classifying attribute-dependent variable (higher homogeneity corresponding to lower values of IE) is given by:
Any categorical attribute CA (from the 100 ones created via the above transformation) with possible values ca1, ca2, ... cak can be used to partition P into subsets Ca1, Ca2, ... Cak, where subset Caj contains all those records from P that have CA = caj. Let Caj contain p1j records of class P1 and p2j from class P2. The Information Entropy of the set P, after this partition, is equal to the weighted average of the information Entropies of the subsets Ca1, Ca2, ... Cak and is given by:
Therefore, the Information Entropy gained by partitioning according to attribute CA, namely the improvement in homogeneity concerning the classifying attribute-dependent variable is given by:
Gain(CA) = IE(p 1, p 2) - IE(CA) (3)
The Uncertainty Coefficient U (CA) for a categorical attribute CA is obtained by normalizing this Information Gain of CA so that U (CA) ranges from 0% to 100 %.
A low value of U(CA) near 0% means that there is no increase in homogeneity (and therefore in classification accuracy) if we partition the initial set according to CA therefore there is low dependence between the categorical attribute CA and the classifying attribute-dependent variable, while a high value near 100% means that there is strong relevance between the two attributes.
Construction of decision tree classifier structures
A decision tree is a class discrimination tree structure consisting of non-leaf nodes (internal nodes) and leaf nodes (final-without child nodes), [23, 25, 28]. For constructing a decision tree we use a training data set, which is a set of records, for which we know all feature-attributes (independent variables) and the classifying attribute (dependent variable). Starting from the root node, we determine the best test (= attribute + condition) for splitting the training data set, which created the most homogeneous subsets concerning the classifying attribute and therefore gives the highest classification accuracy. Each of these subsets can be further split in the same way etc. Each non-leaf node of the tree constitutes a split point, based on a test on one of the attributes, which determines how the data is partitioned (split). Such a test at a decision tree non-leaf node usually has exactly two possible outcomes (binary decision tree), which lead to two corresponding child nodes. The left child node inherits from the parent node the data that satisfies the splitting test of the parent node, while the right child node inherits the data that does not satisfy the splitting test. As the depth of the tree increases, the size of the data in the nodes is decreasing and the probability that this data belongs to only one class increases (leading to nodes of lower impurity concerning the classifying attribute-dependent variable). If the initial data that is inherited to the root node are governed by strong classification rules, then the decision tree is going to be built in a few steps, and the depth of the tree will be small. On the other hand, if the classification rules in the initial data of the root node are weak, then the number of steps to build the classifier will be significant and the depth of the tree will be higher.
During the construction of the tree, the goal at each node is to determine the best splitting test (= attribute + condition), which best divides the training records belonging to that leaf into most homogeneous subsets concerning the classifying attribute. The value of a splitting test depends upon how well it separates the classes. For the evaluation of alternative splitting tests in a node various splitting indexes can be used. In this work the splitting index that has been used is the Entropy Index . Assuming that we have a data set P which contains p records from the 2 classes and where p j /p is the relative frequency of class j in data set P then the Entropy Index Ent(P) is given by:
If a split divides P into two subsets P 1 and P 2 where P 1 contains p 1 examples, P 2 contains p 2 examples and p 1 + p 2 = p, then the values of Entropy Index of the divided data is given by:
In order to find the best splitting test (= attribute + condition) for a node we examine for each attribute data set all possible splitting tests based on these attributes. We finally select the splitting test with the lowest value for the above Entsplit to split the node.
The expansion of a decision tree can continue, dividing the training set in to subsets (corresponding to new child nodes), until we have subsets-nodes with "homogeneous" records having all the same value of the classification attribute. Although theoretically this is a possible scenario in practical situations usually leads to a decision tree structure that is over-fitted to the training data set and to the noise this data set contains. Consequently such a decision tree structure has not good generalization capabilities (= high classification accuracy for other test data sets). Stopping rules have been therefore adopted in order to prevent such an over-fitting; this approach is usually referred to as decision tree Pruning . A simple stopping rule that has been examined in this work was a restriction concerning the minimum node size. The minimum node size sets a minimum number of records required per node; in our work for the pruned decision tree structure described in the Results section a node was not split if it had fewer records than a percentage of the initial training data set records (percentages 5%, 10%, 15%, and 20% were tried).
Finally the constructed Decision tree structure is used as a classifier in order to classify new data sets. In our work we used this classifier to classify both the training data set and the test data set.
Selection of training and test pattern sets
The training-test schemes used in this study
Number of records of Training dataset
Number of records of Test dataset
The standard deviation values are generally smaller that 10%, showing that the Uncertainty Coefficients calculated from each scheme separately, especially the ones of the most relevant features, are similar and consistent.
Fully expanded decision tree
According to the methodology described in the Methods section, we initially construct the decision tree structure with no restriction to the nodes (without pruning). The training data-set used was from the scheme 40%a (Table 1) and had 34 records (heart sound patterns). The rest 50 patterns were used as a test set. The Decision tree was constructed based on the training data set and afterwards using this decision tree the patterns of the test data set were classified in order to investigate the generalization capabilities of the decision tree. Then the percentage of the correctly classified patterns of the test data set (according to the hdisease attribute) was calculated. The classification performance for the 40%a scheme was: 45 patterns were classified correctly (22 AS and 23 MR) while for 5 patterns the classification was wrong (2 AS and 3 MR); therefore the percentage of classification accuracy, is defined as
is 45/50*100 = 90%.
In order to investigate the performance of the decision tree classifier in more detail we calculated, in addition to the above Total Accuracy, also the partial accuracy for AS heart sounds, referred to as AS_Accuracy:
and the partial accuracy for MR heart sounds, referred to as MR_Accuracy:
The standard deviation of all these average values was very low, proving once more that the 16 most relevant features (out of the initial 100 features) contain all the information we need for the differentiation between AS and MR. The conclusions derived from Figure 4 concerning the partial Classification Accuracies are similar to the ones derived above concerning the total Classification Accuracy; with the exception of schemes 80%a and 80%b, in which the test data set for each disease is very small (8–9 patterns), therefore the corresponding partial Classification Accuracies are less reliable. Also we can see that for 6 out of 10 schemes (40%a, 50%a, 50%b, 70%a, 70%b, 80%b) there are no significant difference between AS Classification Accuracy and MR Classification Accuracy, while for the remaining 4 schemes (40%b, 60%a, 60%b, 80%a) the MR Classification Accuracy is significantly higher than the AS Classification Accuracy; therefore in general the classification performance of the decision trees for the MR heart sounds is higher than it is for AS heart sounds. In order to confirm statistically this first conclusion, a t-test was performed with the null hypothesis statement H0:
Mean (Scheme_Average_AS_Accuracy) = Mean (Scheme_Average_MR_Accuracy),
and the alternative hypothesis statement H1:
Mean (Scheme_Average_AS_Accuracy) < Mean (Scheme_Average_MR_Accuracy).
Assuming that the error probability of rejecting H0 while H0 is truth is a = 1%, we found that the null hypothesis H0 should be rejected (with confidence interval 99%). This statistical result is consistent with the above first conclusion; therefore it confirms statistically the above first conclusion. Again the classification total Accuracy, AS_Accuracy and MR_Accuracy for the training data set was 100% for all the examined cases.
Pruned decision tree
Mean (Scheme_Average_Accuracy_support_0%) = Mean (Scheme_Average_Accuracy_support_X%),
and the alternative hypothesis statement H1X% was defined as:
Mean (Scheme_Average_Accuracy_support_0%) > Mean (Scheme_Average_Accuracy_support_X%).
The X% stands for the minimum support levels (i.e. 5% or 10% or 15% or 20%) used individually in each one of the four t-tests. Assuming that the error probability of rejecting H0X% while H0X% is truth is a = 1%, we found that there was a 99% confidence that the null hypothesis should be accepted. This statistical result confirms once more the above conclusion for the decision tree pruning.
The decision trees can be used with high levels of success for the differentiation between AS and MR. The decision tree model is simple and clinicians are familiar with it, because they use a similar way when they make differential diagnosis. Therefore the decision trees can be used as a basis for decision support systems, giving to the clinicians dealing with the heart sound diagnosis, especially to the ones in rural areas, in homecare, the primary healthcare etc, almost immediately an advice that helps them to make better heart sound diagnosis. This capability can reduce the costs and improve the quality of the healthcare for the cardiological problems.
There is a small subset of the initial features that contain most of the information required for the differentiation. Using Relevance Analysis we can determine this critical subset of features, which then can be used for constructing the decision tree. Also the diagnosis for any new data set will be based only on this subset of features. In this way the required computational effort for training and using these decision trees significantly decrease.
In the specific discrimination problem the Fully Expanded decision tree structures have similar levels of Generalization and Classification Accuracy for new data in comparison with the Pruned decision tree structures.
Increasing the size of the training data sets (more patterns) improves the Classification Accuracy and the general reliability of the system. This is reasonable because the decision tree is trained with more samples that cover more cases.
The generalization capabilities of the decision tree based methods for problems similar to the one examined in this paper were found to be satisfactory. This is very important, due to the difficulty and the high cost of having enough training data for every possible case. The decision tree structures were tested on various training and test data set and the Classification Accuracy was found to be consistently high. However having more training data the decision trees can produce more trustworthy predictions.
The general heart sound diagnosis problem can be divided into a number of simpler problems  such as: detection of systolic murmur, detection of diastolic murmur, determination of the type of the murmurs (crescendo, decrescendo), determination of the frequency content (low, high, medium), detection of Mid-systolic click, arrhythmia, of premature ventricular contraction, differentiation between heart diseases with similar heart sound signals, differentiation between Opening Snap, 2nd heart sound split, and 3rd heart sound , differentiation between the 4th heart sound, ejection clicks and the split of S1etc. All these simpler problems can be solved by separate specialized decision support systems, which can be based on different methods, algorithms and features. The partial diagnosis given by these decision support systems can then be combined to give a total diagnosis. The combination of all these decision support systems can lead to an integrated decision support system architecture for Heart Sound Diagnosis.
Further research is required for the development of a methodology for the selection of the most appropriate decision tree structure and for improving the Classification Accuracy. Also further research is required in order to investigate the applicability and suitability of decision tree-based methods for other significant problems in the area of heart sound diagnosis.
The authors would like to thank the clinician Dr D. E. Skarpalezos for his clinical support, Dr G. Koundourakis, and Neurosoft S.A. for their support and provision of Envisioner, a data-mining tool that was used to execute algorithms related to the decision trees.
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