ASPEL S.A.

PL 32-080 Zabierzów, os. H. Sienkiewicza 33

tel. +48 12 285 22 22, fax +48 12 285 30 30
www.aspel.com.pl

Operation Manual

CardioTEST
Software version from 3.73.00

Zabierzów, 15.11.2018, Edition XVII

Operation manual CardioTEST Software IU-AT-39-B_XVII_ENG

We are pleased to thank you for the purchase of the CardioTEST

software designed for stress tests.

ASPEL company has a great pleasure to present the product, which

is a result of many years of researches and experience acquired
during direct contacts with our clients. You choose the quality,
durability and high efficiency - the features that characterize the
CardioTEST device.

CardioTEST complies with the standards of the Polish Cardiology

Association.

ASPEL company offers the wide assortment of the equipment and

accessories within the ECG diagnostics, such as: As CARD series
ECG equipment, HolCARD 24W ECG analysis systems using Holter
method, HolCARD CR-07 long-term blood pressure recording
system, CardioTEL tele-medical systems and carts and cases for
ECG equipment, ECG cables, electrodes and recording paper.

Please read carefully this usage instruction, because it includes all

necessary guidelines for safe installation, usage and maintenance
and several practical advices that allow to optimize the software
usage.

Keep this instruction for the later consultations.

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Contents
1. INTRODUCTION......................................................................................................................................... 4
1.1. GENERAL INFORMATION ............................................................................................................................................... 4
1.2. LICENSE AGREEMENT .................................................................................................................................................. 4
1.3. ASKEY KEY ................................................................................................................................................................ 6
1.4. HARDWARE REQUIREMENTS ......................................................................................................................................... 7
1.5. INSTALLATION ............................................................................................................................................................. 7
1.6. MANUFACTURER OF THE SOFTWARE ........................................................................................................................... 13

2. PREPARE TO WORK WITH THE CARDIOTEST SOFTWARE ...................................................... 14

2.1. STARTING THE SYSTEM .............................................................................................................................................. 14
2.2. STARTING THE PROGRAM ........................................................................................................................................... 14

3. PATIENTS AND TESTS DATABASE ..................................................................................................... 15

3.1. PATIENT DATA ........................................................................................................................................................... 16
3.2. DELETING PATIENT .................................................................................................................................................... 17
3.3. ADDING NEW PATIENT ................................................................................................................................................ 17
3.4. TEST DATA ................................................................................................................................................................ 17
3.5. DELETING THE TEST ................................................................................................................................................... 18
3.6. SELECTING THE PATIENT ............................................................................................................................................ 18
3.7. ARCHIVING................................................................................................................................................................ 19

4. PERFORMING THE TEST ...................................................................................................................... 22

4.1. ELECTROCARDIOGRAPHY REST TEST .......................................................................................................................... 24
4.1.1. Beginning of the test...................................................................................................................... 24
4.1.2. Running the test............................................................................................................................. 24
4.1.3. Ending the test............................................................................................................................... 28
4.2. ELECTROCARDIOGRAPHY STRESS TEST....................................................................................................................... 28
4.2.1. Starting the stress test ................................................................................................................... 37
4.2.2. Manual control of the device......................................................................................................... 37
4.2.3. Online trends module .................................................................................................................... 39
4.2.4. Overview of the recorded ECG module......................................................................................... 41
4.2.5. Blood pressure measurement ........................................................................................................ 43
4.2.6. Ending the stress test..................................................................................................................... 44
4.2.7. Report preview module.................................................................................................................. 46
5. BROWSING THE RECORDED TESTS.................................................................................................. 47
5.1. BROWSING THE ECG SIGNAL ..................................................................................................................................... 47
5.2. BROWSING TRENDS, HISTOGRAMS AND CHARTS ........................................................................................................... 54
5.3. EXPORTING THE ANALYSIS RESULTS ........................................................................................................................... 58

6. REANALYSIS OF THE RECORDED TEST .......................................................................................... 59

7. PROGRAM CONFIGURATION.............................................................................................................. 62
7.1. SETTINGS ................................................................................................................................................................. 62
7.2. PREFERENCES .......................................................................................................................................................... 62
7.2.1. Ergometr ....................................................................................................................................... 63
7.2.2. Interaction with the treadmill equipped with the inclinometer ..................................................... 64
7.2.3. BP.................................................................................................................................................. 65
7.2.4. Configuration how the ECG recording is displayed ..................................................................... 65
7.2.5. Configuration of the stress test run ............................................................................................... 66
7.2.6. Report configuration ..................................................................................................................... 67
7.2.7. Definition of the ECG lead groups................................................................................................ 69
7.2.8. User identification......................................................................................................................... 69
7.2.9. Protocols ....................................................................................................................................... 70
7.3. DATABASE ................................................................................................................................................................ 71

8. SECURITY .................................................................................................................................................. 73

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1. Introduction
1.1. General information

CardioTEST software is designed for conducting the electrocardiographic stress tests

and classic rest tests. It gives the user the powerful diagnostics tool. The basic
features of the software:
– possibility of continuous high quality recordings of 12 ECG leads runs,
– cooperation with the treadmill or cycle-ergometer and ECG transmitter,
– full archiving of the performed tests,
– printout of the ECG records on the laser printer (A4, 3,6 format or 12 leads),
– continuous measurement:
– heart rate,
– level and deviation of ST section in 12 leads,
– ventricular arrhythmia,
– presentation of the ECG records in several different modes (3, 6 or 12 leads),
– presentation of the analysis results in the form of trends, histograms,
3-dimensional diagrams (3D),
– signalization of the assigned parameters excess (heart rate, ST level),
– signalization of the ventricular arrhythmia detection,
– quick and easy changes in parameters of the ECG recording presentation
parameters (move, amplification),
– several types of filters that allow elimination of the interferences (digital filters),
– possibility of the software configuration depending on the user requirements,
– possibility of the comparison of the changes in the ECG curve shape,
– definition of the own test reports,
– possibility of the recording for the rest ECG records.

1.2. License agreement

This agreement includes all legal stipulations agreed between the Buyer, as the end
user, and ASPEL S.A. company, thereinafter referred to as the Manufacturer. If, the
Buyer does not accept the conditions of this agreement, he should without any delay
return the complete product to the distributor to receive the full return of the incurred
costs. Subject of the license

1. CardioTEST, thereinafter referred to as the Software, is the property of the

manufacturer and the cooperated companies listed in the accompanying
materials. The Software is protected by the Polish law (Copyright and related
rights law, Journal of Laws, No. 24, pos. 83) and international decrees about
the protection of the intellectual and legal property. Therefore, the purchased
Software shall be treated in the same way as any other element of the
copyright law (e.g. book, music recording). The Manufacturer does not sell
for The Buyer the Software, and only grants him the rights for usage

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according to the conditions of this Agreement. The Manufacturer reserves the

all rights not directly expressed in the Agreement. The Buyer shall not have
any rights to copy, rent, lend or transfer in other ways the License granted for
him, and to use the Software in other areas of the exploitation than reserved
in this Agreement, without prior written consent of the Manufacturer.

2. The Manufacturer grants the Buyer all rights for usage of the Software on
one computer station in the same time. To obtain the Multiuser License, the
Buyer shall contact the Manufacturer or his authorized distributors.

3. The Buyer shall not have any rights to copy, modify, recompilation and other
changes in the Software and accompanying documentation.

4. The Agreement and all vested for the Buyer rights, shall be ineffective, if the
Buyer will not comply with any of the conditions of this Agreement. In such
case, the Manufacturer shall assert his rights defined in the proper
regulations. The claims resulting from the infringe of the Manufacturer
copyrights shall be effective also after the termination of this Agreement.

Limitations of the guarantee

The Manufacturer guarantees that the Software shall be in the considerable extent
functioning according to the attached documentation and, that all materials, such as
floppy discs, CD and other carriers, documentation, etc. shall be free from any
defects in the materials. The manufacturer grants the guarantee for the usage of this
materials on the condition of the regular exploitation and according to their
destination for the period of one year from the purchase date confirmed by the
invoice. All claims resulting from this guarantee shall be limited to the period of one
year.

None of the distributors and persons representing the Manufacturer shall not extent
and change the above mentioned stipulations. The Manufacturer does not guarantee
that the Software shall in full and without any problems fulfil the anticipation of the
buyers. The Buyer shall bear all the risks relating to the possibilities of the purchased
Software for the particular purpose.

Buyer's entitlements

The responsibility of the Manufacturer consists in:

1. repair and exchange of the materials that are not conforming with the
conditions of this Agreement, following the return of such materials to the
manufacturer or his authorized distributor along with the copy of the invoice,
or

2. in case, when the exchange of the materials shall be impossible, the Buyer
can return the goods along with the bill to the Manufacturer or his distributor

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obtaining the refund for the Software.

The choice of the method regarding the satisfy the Buyer's claims belongs to the
Manufacturer.

Exclusions from the liability for the losses

In no case, the Manufacturer or his authorized distributors shall be liable for any
damages or losses directly or indirectly resulted from the usage or inability of the
usage of the Software, taking into account all profit losses of the company,
discontinuity in the company operations, losses of the information and other
situations not included in this Agreement, even in case, when the manufacturer was
informed about such possibility.

In no case, the liability of the Manufacturer against the Buyer on the basis of this
Agreement shall not exceed the amount that the Buyer paid for the License for the
Software usage.

1.3. AsKEY key

The proper functioning of the Software is only possible in the situation when the
protective AsKEY key is connected to the USB port. This key allows prevents illegal
duplication of the Software.

Figure 1. Software protective key

To provide the proper functioning of the CardioTEST software, the AsKEY key should
be continuously connected to the USB port. Do not remove the key, when the
program is running. After insertion of the AsKEY key to the USB port, wait 1-2
minutes until the program starts and MS Windows starts all drivers of the key.

Loss of the protective hardware key can lead to the loss of the rights for the
Software.

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1.4. Hardware requirements

CardioTEST software for the exercise tests should be installed on the IBM
compatible computer, according to the standard EN 60950.

Minimal requirements:
– operating system: Windows 7, Windows 8.1, Windows 10 (32 bit and 64 bit),
– processor: PENTIUM 1600 MHz,
– 2GB RAM,
– CD-ROM or DVD
– hard drive min. 100 GB,
– color monitor SVGA 17”,
– laser print HP LaserJet.

CardioTEST software allows the cooperation with the following devices:

– treadmill or cycle-ergometer,
– ECG signal processing module in the form of:
AsCARD MrGrey,
AsCARD Green, Mint
AsCARD Mr. Red, Red3,
AsCARD Mr.Blue, Blue3,
AsCARD Mr.Silver, Silver3
AsCARD Mr.Gold, Gold3,
AsCARD Coral,
AsCARD B5*,
AsCARD B56*,
AsCARD A4*,
AsPEKT 500,
the module built-in the treadmill or cycle-ergometer.
* 2.0 or higher software version

1.5. Installation
The CardioTEST Software © ASPEL is supplied on a CD-ROM disk. We begin the
installation by placing the disk in the reader. The main board of the installation
program will be displayed on the monitor screen. It enables the installation of the
CardioTEST program, the opening of the instructions for using the program and
access to the demonstration versions of ASPEL’s program offerings.

Figure 2. Main Installer Menu

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The installation program provided on the CD allows for installation or update from
previous versions of CardioTEST. An update consists in substituting an older version
of the system with a more recent one, without any changes to the database. An
update is performed in the same location where the previous version of CardioTEST
was installed.
If you would like to perform a new installation on a computer with another version of
the CardioTEST system already installed, but you do not want any changes to be
made to the previous CardioTEST system files, you need to make sure that the
location selected for the installation is different than the folder where the previous
version was installed.
• You need to have administrator rights to install the CardioTEST. After the
installation is finished, shortcuts to the installed programs are added to the
desktops of all users.
• During the installation, it is advised to use default paths for the installation.
• No spaces are allowed in folder names when inputting custom paths.

To begin installation, select the item <Stress>. A window will open in which we can
select the installation language:

Figure 3. Window for selecting the installation language

Clicking the <OK> button will launch the welcome window:

Figure 4. Start of the installation program

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In this window, click <Next> to start the installation/update process.

The CardioTEST program is a legally protected product and every user is obliged to
familiarise himself with and abide by the licence agreement. After reading the licence
and accepting the agreement, select the button, <I agree>.

Figure 5. Licence agreement window

Selecting this button will activate the <Next> button, which will allow you to go to the
next step. The next installer window allows you to install the required AsKEY drivers.
The installation occurs with the aid of an additional program which will be activated
when the <Next> button is pressed. Go through the entire installation process with
the additional program activated and then return to the next installation step.

Figure 6. ASCII key installation window

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The next step of the installation process is different, depending on whether another
version of CardioTEST is installed on the computer or not:
• New Installation (CardioTEST is not installed on the computer)
• Update (there is another version of CardioTEST already installed on the
computer)

New Installation

If there is no other version of the CardioTEST installed on the computer, the next
step of the installation consists in selecting the location where CardioTEST will be
installed. The default recommended path is already entered in the window. You can
select your own location for the installation by clicking the <Browse...> button. Select
the appropriate location and proceed to the next step by clicking <Next>.

Figure 7. CardioTEST installation location selection window

In this step, enter the location where the database i.e. the patient data files,
examinations, devices etc. will be stored. You can accept the recommended location
or select your own location by choosing the appropriate folder after clicking the <...>
button.
If you want the program to operate on an existing database, in this step you can
select the folder containing this database.

In order for the program to work properly for every user, the database must be in a
location accessible to all users.

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Figure 8. Database location selection window

In this step, the last stage of the installation process begins, which consists in the
actual installation of CardioTEST. Selecting <Install> initiates the process of copying
the necessary system files to the computer’s disk. Once this process is finished, the
finish installation window will appear, giving you the option to run CardioTEST.
Shortcuts to CardioTEST will be created. Click <Close> to exit the installer.

Figure 9. Finish installation window

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Update
If you have another version of CardioTEST already installed on your computer, a
dialogue box will appear with a question whether you want to update the program (no
changes will be made to the database) or install a new version (without any changes
to the previous version).

Figure 10. Update or new installation selection window

Upon choosing the <Update> option, the installer will display a dialogue box with the
location of the update (the folder, where the previous version of CardioTEST is
installed).

Figure 11. Update information window

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To finish the update process, select the <Install> button. The program files will be
updated and the finish update window will appear with the option to run CardioTEST.
Remember to insert the AsKEY into a USB port in your computer. Shortcuts to the
updated versions of CardioTEST will be created. Click <Close> to exit the installer.
If you select the option <NEW INSTALLATION>, you will go back to the installation
path described above in the ‘Installation’ subsection.
Now, place the AsKEY key which was supplied with the installation disk in the free
USB port of the computer and wait (2-3 minutes) until the MS Windows system
installs the key, which will be confirmed by the appropriate message in the lower
portion of the screen.
When all of the described actions are completed, the program is ready to run.

1.6. Manufacturer of the Software

ASPEL S.A.
os. H. Sienkiewicza 33
32-080 Zabierzów
POLAND

Tel + 48 12 / 285 22 22
Fax +48 12 / 285 30 30

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2. Prepare to work with the CardioTEST software

2.1. Starting the system

During the first stage of the system operation, power for all system elements should
be started. The order during start-up operation is unrestricted. However, the user
should remember that the system consists out of the following elements: computer
system, ECG signal processing module, treadmill or cycle-ergometer. The
CardioTEST software will operate properly, only when all elements of the system are
powered and running.

2.2. Starting the program

Turning on the computer power allows the automatic start-up of the MS Windows
operating system. If, the CardioTEST © Aspel software is properly installed, then
along many icons on the desktop the program start icon will be displayed (Figure
12.). This the shortcut that allows quickly start the program. Because the program is
protected against unauthorized access with the hardware key, the user should
remember to verify whether the key is connected to the computer. Without the proper
key, the program will not be started.

Figure 12. CardioTEST program icon

After starting the program (double click on the icon), the start window will be
displayed on the monitor (Figure 13).

When the window is displayed, the program is ready to work. The main window
includes 6 buttons that allow the access to the all basic functions of the software.
Within the buttons section the description are available, that facilitate to make the
proper choice.
– Patient - patients and their examinations data base,
– ECG - for classic electrocardiography examination,
– Exercise - for exercise stress test,
– Examination - overview of the examinations included in the archive,
– Settings - configuration of the CardioTEST © Aspel program,
– Exit - stops the operation of the CardioTEST © Aspel program.

To select the function, place the cursor on the appropriate button and click with right
button of the mouse. The user can use also the keyboard with the hotkeys.

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Figure 13. CardioTEST program main window.

3. Patients and tests database

All imported data and all performed tests are stored in the database. Access to this
data is allowed through the patient module. Pressing the [Patient] button on the main
window allows to open patient data window (Figure 14).

Active storage

Patients list

Patient data

Description
Tests list

Figure 14. Patient data window

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All information in the module are divided on two main parts. In the upper section of
the module, all data stored in the program are represented. This data refer directly to
the individual patient. Next to the data, the buttons are available that allow to perform
certain operations connected only with this data. In the lower section of the module,
the patient tests list is presented along with information about such tests.

In the upper part, the selection window for the actually viewed database is available.
The program allows to store the tests in the data storages created by the user, e.g.
for each system user one data storage with the pool of only his patients.

3.1. Patient data

CardioTEST © Aspel program allows to store the following data for each registered
patient:
Name, Birth date,
Identification number, height,
Address, Weight,
Telephone, Sex,

The program displays this information on the right side of dialog window for the
actually selected patient. The actually selected patient is the patient, who on the
patient list is displayed on the dark background.

To modify the data for the actually selected patient, the user must perform the
following operations:

1. Select [Data Edition] button. The separate dialog window will be displayed
on the screen, that allows to modify all respective patient data.

2. Place the blinking cursor on the selected field.

– Method A. Move the cursor over the given field pressing the left button of
the mouse. The blinking cursor will move to the selected field.
– Method B. Press the <TAB> key. The blinking cursor will move to the next
field of the patient data. By pressing the <TAB> key proper number of
times, the user can move the cursor to the proper place.

3. Insert the new data.

– Handling of each patient data field is done according to the standards
found in MS Windows. To cancel the characters, use <Backspace> key on
the keyboard, to move the blinking cursor, use arrows keys.

4. To confirm the operation, select [OK] button.

– Only by selecting the [OK] button, any data changes can be saved in the
program. To return to the previous settings, use [Cancel] button or close
the window using the small icon in the upper bar.

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3.2. Deleting patient

Any patient can be deleted from the database. However, remember about the
consequences of this operation. When the patient is deleted, all his tests are also
deleted, not only the analysis results and all additional information inserted by the
user, but also recorded ECG signal.
Remember !!! Deleting operation is the operation that cannot be recalled. This
operation results in the loss of the all possessed documentation for the patient.
To delete the actual patient from the database, select the [Delete patient] button.
If this test was recorded, the test will be closed, and then all information about
the patient will be deleted from the program. On the screen, the window asking
for the confirmation of the operation will be displayed, because the deleting
operation cannot be recalled.

3.3. Adding new patient

To enter the data of the new patient, use the [New Patient] button. The dialog
window will be displayed on the screen, the same as in case of the patient data
modification, that allows to enter all saved personal data.

3.4. Test data

Each patient can have any number of the recorded tests. All such tests are
represented on the [Tests list]. This list includes the following information:
– test number (No.),
– test date,
– duration of the test,
– test status.

The status informs the user about the type of the recorded test.

Status Meaning
STRESS Recording of the electrocardiography stress test
AUTO Recording of the electrocardiography rest test in the AUTO mode
MANUAL Recording of the electrocardiography rest test in the MANUAL mode

Information regarding the actually selected test are displayed next to the tests list.
This information includes:
– data regarding the used medicaments,
– recommendations for the test,
– causes of the tests ending,
– description of the changes in the ST section,
– interpretation of the test,
– general annotations.

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3.5. Deleting the test

Because each test is using a lot of space on the computer's hard drive, the tests are
often deleted to provide the possibility of the next recordings. To delete the test,
select the proper test and press the [Delete] button. The window asking for the
confirmation of this operation will be displayed on the screen. To delete the test,
select [OK] button.

Remember!

The operation of deleting patient or his data cannot be recalled.

3.6. Selecting the patient

After starting the CardioTEST program, [Stress] and [ECG] buttons are displayed in
the gray color ( the buttons are inactive). To activate these functions, select the
patient for which the new test will be performed. To do this, on the main screen select
the [Patient] button. As the results, the dialog window will be displayed on the screen
that allows to enter the data for the new patient or select the patient saved in the
archive (Figure 15).

Active storage

Patients list

Patient data

Tests list Description

Figure 15. Selecting patient window

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If the patient name is included on the list, select the proper line and confirm the
selection by pressing the [OK] button. If you want to enter the data for the new
patient, press the [New Patient] button and fill the dialog display represented on
Figure 16.

Figure 16. Patient data window

3.7. Archiving

CardioTEST (c) provides the function for collecting the tests and data about the
patient in many different data storages. The data storages can be located on the
computer hard drive on which the program is run, they can be located on the hard
drive of the other computer, e.g. on the network disc, on the CD-RW, DVD-RW or on
the other archiving device. However, we have to remember, that the work with the
tests recorded on the external devices or on the remote data storages can be very
slow. Therefore, we recommend the work in the local data storage (e.g. created on
the local disc), and export such data from time to time to the other data storages for
archiving purposes.

The detailed method regarding creation of the data storages is available in chapter
7.3 Data base. In this chapter we would like to describe only the archiving problems
for the selected tests by saving them in the earlier prepared data storages.

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Patients list

Actual size of the

data storage
Archiving the selected patients

The Patient Data window provides the function of marking/selecting several patients
in the same time. Each marked patient is draw on the grey bar on within the Patient
List (see Figure above).

To mark/select several patients, press and hold the <Ctrl> key on the keyboard, and
then move the cursor of the mouse over the selected patient name on the list and
press the left button of the mouse. Holding the pressed <CTRL> key, select the next
patient, etc. Each selected patient will be marked on the grey background.

There is available also the second method for marking/selecting patients, it is used in
situations when we want to select greater number of the items form the list. To do
this, select first patient. Then, press the <Shift> key on the keyboard and hold it.
Move to the position of the last patient that will be marked and holding the pressed
<Shift> key, mark this patient. After performing these operations, all marked patients,
from the first one marked on the list to the last one on the list. Both described
methods can be also combined together.

Such selected patients we can copy to the any previously created data storage (for
more information about creating the data storages, see chapter 7.3 Data base). To
do this, select [Copy Patient] button from the dialog window. The list of available
data storages will be displayed on the screen. To these data storages we can then
copy all patients, e.g. tests for the recording on the DVD.

However, the described operation allows only to copy. The test are not removed from
the original data storage. This is because of the data safety. If we want to copy the

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test, select the [Delete Patient] button. All patients marked on the list together with
their tests will be removed from the active data storage.

Archiving the selected tests

In situation, when the patient has several tests, and we want to copy only the
selected test, use the [Copy] button. Only the selected tests for the selected patient
will be copied to the defined data storage. The selection process is performed in the
same way as described above - by using the <Ctrl> or <Shift> key.

Preparing data storage to the recording on CD or DVD

If we want to archive the tests on CD or DVD, then the easiest way is to create the
temporary data storage that will be collect the tests to the further recording on the
selected carrier. We can then create the data storage named "Tests for recording on
CD" that will be the temporary image of the disc, copy the selected patients or select
the test until the full volume of the CD. After preparing such data storage, it should be
recorded on the CD by using the external program delivered together with the
recorder.

To facilitate the control of the collected data, to not exceed the volume of the disc,
there is available the field that informs the user about the actual size of the data
storage. After selecting the data storage on the list, the actual size of the data
storage is read and displayed on the lower part of the window.

The second method for archiving on the CD and DVD requires usage of CD-RW and
DVD-RW carriers. Such discs can be configured in the such way, that they will be
visible as the normal computer hard drive. Then create the data storage on such
discs. Then, we can copy the tests from the level of the Patient data window directly
with using [Copy Patient] or [Copy] function.

Practical notices
– Test data storages allow to organize the work in different ways. They can be
used to collect the data in separate data storages for the patient handled by the
other physicians - then each physician has its own data storage.
– In situation, when the office is visited by many patients, we can create new data
storages, e.g. every quarter and collect in them new patients. In this way, the
program will operate much faster and the archiving operation will be much
easier. The recorded CD disc can be described with information regarding the
scope of the archiving procedure.

There is also the possibility to collect the archive test on the hard drive of the
selected computer, so each user of the CardioTEST program will have the access to
them.

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4. Performing the test

Each test begins with the proper start-up of the program, according to the instructions
described in the chapter 2. Remember, to turn on the power for each element of the
system. The start-up procedure is ended, when the main program window is
displayed on the screen (Figure 13).

Contraindications for performing exercise tests

There are many contraindications for performing exercise tests. They can be divided
into absolute contraindications that definitively prevent the performance of a trial and
relative contraindications, in which the performance of exercise test may be possible
after thorough analysis of patient’s safety. The final decision is made by the doctor
performing the exercise test.

As absolute contraindications are classified, e.g.: recent myocardial infarction, rest

chest pains on the examination day, significant decrease or increase of the ST
section in rest ECG as an expression of acute ischaemia, open cardiovascular
failure, rhythm disturbances growing during exertion, venous thrombosis or other
recent thrombotic processes, recent arterial embolism, acute communicable
diseases, dissecting aortic aneurysm, or serious organ and system diseases.

As relative contraindications are classified, e.g.: serious arterial hypertension

(>200/110), pulmonary hypertension, significant anaemia, decompensated metabolic
diseases such as diabetes and hyperthyroidism, electrolyte disturbances, or diseases
and disturbances preventing correct contact with examined person.

Responsibilities of the doctor and staff

The doctor signing the examination report is responsible for reviewing and verifying
the results generated automatically by the program. For this purpose is used the
Analysis Review Module, which presents the saved signal of patient’s heartbeat.
Please remember that wrong diagnosis entails incorrect patient treatment process,
which in turn may worsen the patient’s health status and, in certain cases, cause
patient’s death.

When performing exercise test please pay special attention to:

1. Thoroughly and correctly connected electrodes

The quality of ECG signal presented in the program depends on the quality of
connection of electrodes to patient’s body. Please correctly prepare the patient’s
body and attach the electrodes, so that no additional disturbances are generated
during movement.

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2. Correct implementation of patient’s date of birth

The patient’s date of birth is used to calculate his/her age. On the basis of age is
calculated the value of maximum HR that the patient can achieve in order to maintain
the required level of safety. Because of that, please pay particular attention to correct
implementation of patient’s date of birth during the registration.

3. Correct selection of ECG channel for analysis

The ECG signal analysis during the exercise test is done on the basis of two selected
channels. The system’s operator is responsible for checking before the start of
analysis if the currently chosen channels are valid and best for given situation. If
necessary, replace them in the program. If the channels are chosen incorrectly, they
may cause wrong analysis – signalising non-existent disturbances or not detecting
real disturbances in patient’s body.

4. Correcting the settings of ST measurement points during the test

To the very important tasks of the system staff belongs controlling and, if necessary,
correcting the ST measurement points when performing exercise test. The location of
ST measurement points changes alongside the progress of exercise test. If those
points will remain unchanged, this will have negative impact on the automatically
calculated ST change values and in consequence may influence an incorrect
diagnosis of patient’s condition.

5. Burdening the patient before the proper exercise

When performing the exercise test, please constantly control the patient’s condition
in order to assess if he/she is not burdened with too big exercise. In case when the
patient has malaise, immediately end the test.

Preparing the patient

To provide the proper quality of the ECG signal, the patient must be prepared to the
stress test.
– The disposable electrodes for the exercise stress tests are used.
– If necessary, the place in which the electrodes will placed must be shaved.
– The place where the electrode are placed must be degreased and cleaned form
the dead epidermis:
o usage of the abrasion paste is recommended,
o usage of the ethyl alcohol is forbidden.
– The position of the electrodes should comply with the standard Einthoven
leads (if this refers to the diagnostic purposes).
– All cables must be static, and cannot overload the electrodes.

Please, remember to check that there are any contraindications for the exercise
stress test.

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4.1. Electrocardiography rest test

4.1.1. Beginning of the test

To begin the test, select the patient form the database. In this case, we use the
patient database module described in the chapter 3. When the patient is selected,
the personal data of the patient are displayed on the screen and all diagnostics
options of the CardioTEST program are activated. After selecting the [ECG] button,
you can move to the appropriate test.

4.1.2. Running the test

When the test is started, the ECG module window (see below) is displayed on the
screen and the ECG signal is displayed in the continuous way. Saving of the test in
the database can be performed in two modes: AUTO and MANUAL. All operations
are performed using the lower console (ECG console).

Figure 17. Rest test module window

Sections of the ECG module window

– Upper console - this part of the screen includes all information regarding the
course of the test
– Lowe console - the line with buttons for the controlling of the test
– ECG recording parameters - in this line all information regarding the ECG
recording are displayed. These are, successively:
o amplification ( 2.5mm/mV, 5mm/mV, 10mm/mV, 20mm/mV),
o move ( 25mm/s,50mm/s,100mm/s ),
o muscular filter (25 Hz or 35Hz),
o mains filter, 50Hz.
– ECG recording window - section of the screen, in which the recordings of the
ECG test are displayed

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Description of the upper console

In the upper part of the screen, the line with the description of the actual test is
displayed.
Apparatus status Actual HR VE number Progress bar

Figure 18. Upper console

Information displayed in the apparatus status filed:

Status Meaning
OK Patient is correctly connected
INOP Improper contact of electrodes with patient body

If, in the program preferences (see chapter 7.2.5) the automatic option of the
ventricular arrhythmia detection is enabled, then in the [VE number] field, the
number of the detected ventricular beats in the last minute is displayed. This is very
important information for the doctor, that can help to make decision about necessity
to break the exercise stress test, because the test is live threatening. Additionally, in
the upper part of the screen, on the right side, on the title bar, the information about
the type of the detected ventricular arrhythmia is displayed.

Description
of the

The ventricular arrhythmia detection is signalled with sound that lasts for about 15
seconds from the detection rime (if in program preferences, the acoustic signalling
option is enabled). The signal can be paused until the new ventricular arrhythmia is
detected by pressing ECG button. Each ventricular arrhythmia detected by the
program is recorded on the events list and can be viewed and verified in the test
overview module (see chapter 5).

The Progress bar is displayed at the time, when the test is saved in both, AUTO and
MANUAL mode. It represents the volume of data recorded in the graphical and
numerical way. Using the MANUAL mode, the program allows to record up to 60
minutes of the ECG recordings, and in the AUTO mode up to 11 seconds (3 seconds
preceding the time of the command selection and 8 seconds after the command is
selected).

Description of the lower console

The user can control the test by using the buttons displayed in the lower console.
Each button is associated with the function keys on the computer's keyboard
(description on the button). Thanks to this, the user during the test can quickly enable

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the specific function of the program. The general view of the lower console is
represented on Figure 19.

Figure 20. Lower console

Description of the functions and buttons:

– ESC - cancel the alarm associated with the ventricular arrhythmia detection,
– F2 Auto - allows to begin the test in the automatic mode,
– F3 Manual - allows to begin the test in the manual mode,
– F4 Stop - end of recording,
– F5 Pause - allows to stop the ECG run on the screen,
– F6 1mV - 1 mV calibration impulse and correction of the isoelectric line location,
– F7 Events - allows to enter the marker in recorded ECG along with the printout,
– F8 Print - printout of the ECG signal visible on the screen
– F9 Screen X - allows to select the ECG display mode,
– F10 Group X - allows to change the group of the leads displayed on the screen,
– F11 Lead - allows to select the particular leads displayed on the screen,
– Return - allows to end the test.

Description of the ECG recording window

The main part of the screen is designated for presentation of the real ECG course of
the test for the patient. Taking into consideration the diagnostics requirements, the
ECG signal can be draw in several modes (3, 6, 12 leads). Figure 21 presents
different modes of the ECG drawing depending on the user requirements.
To change the manner of the display user must press the [F9 Screen X] button. In
case, when on the screen presented is less than 12 leads, the [F10 Group X] button
allows to change the leads group defined earlier. The [F11 Lead] button allows to
select the particular leads presented on the screen.

Mode 1. Preview of 3 selected leads Mode 2. Preview of 6 selected leads

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Mode 3. Preview of 12 selected leads Mode 4. Preview of 12 selected leads

Figure 21. Mode of ECG course presentation

Changing the recording parameters

Any changes in rate, amplification and filters can be done by placing the cursor on
the description in the lower part of the screen and clicking with the left button of the
mouse. 25 Hz and 35 Hz filters are excluding each other (they cannot be enabled in
the same time). User can use also the shortcut keys:
[Speed] - left, right arrow (or gray +/-),
[Amplification] - up, down arrow.

Recording the ECG test

When the ECG module is started, the signal form the AsCARD apparatus is
displayed in the continuous way. Saving of the test in the database can be performed
in two modes: AUTO and MANUAL. All operations are performed using the lower
console (ECG console).
AUTO mode – records 11 seconds of the signal (3 seconds before pressing + 8
seconds after pressing the AUTO button) and allows to print the test with the printer.
By default, the leads displayed on screen are printed, but they can be changed - in
the window that appears on the screen after 11 seconds. Thus window allows to
make decision, whether the test should be saved or printed and set the other printout
parameters.
MANUAL mode – allows to record the longer fragments of the ECG signal – the
limitation are referred only to the volume of the computer hard drive. After ending the
recording in this mode, there is no possibility to make prints automatically. To print,
the user has to use the Rerview Examination module.

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4.1.3. Ending the test

After ending the recording in the AUTO or MANUAL, the dialog window is displayed
that allows to save the test and print the test in the AUTO mode.

Figure 22. Ending the rest test in the AUTO mode

Figure 23. Ending the rest test in the MANUAL mode

4.2. Electrocardiography stress test

When the patient is selected, the buttons on the main window became active. To
start the exercise stress test, the user has to press the [Stress] button. The dialog
window will be displayed on the screen that allows to enter additional data regarding
the test (Figure 24).

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Figure 24. Parameters of the stress test

The dialog window allows to enter the following data:

– %PMHR – information which percent of the maximum heart rate is the target heart rate
– Preference - defining the parameters that control the program operation
– Test Protocol – name of the test protocol,
– Indication – text field with the recommendations description,
– Medicines – filed with information about any medicine taken by the patient.

The button marked with [?] allows to enter several standard test descriptions.
Confirmation of the entered data ([OK] button) allows to start the test. The window
with ECG recording is displayed on the screen.

Test protocols

There are three types of test protocol available:

1. Individualised
It is a test built on the basis of patient’s individual needs and capabilities. After
pressing the <OK> button, on the screen will appear a new window with additional
information determining the test. The patient’s age and his/her proper capacity are
shown on top of the window. Below you can check the class of forecasted capacity.
A window with selection list will appear after pressing the < ? > button. You can
implement the data by clicking the chosen option twice with left mouse button. In
order to remove the implemented value, press the < x > button. The next field is
used to fill out the VSAQ capability assessment questionnaire. After pressing the
< ? > button a VSAQ questionnaire will appear, in which you can choose the
appropriate option. In order to remove the implemented value, select the
< x > button. On the right side of window is shown the forecasted capability that
depends on the patient’s age and data implemented in this window. If necessary,
the value can be set independently.

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Figure . Window for implementation of data for Individualised test

Graded
After choosing this option in the window will be available a list of graded tests.
Ramp
After choosing this option in the window will be available a list of Ramp type tests.
New graded and Ramp tests can be added in the Settings module. Details are
described in Chapter 7.2.9.

Elements of the stress test window:

– Upper console - this part of the screen includes all information regarding the
course of the stress test.
– Low console - the line with buttons for the controlling of the stress test.
– Averaged QRS complex - section in which the averaged QRS complex is draw
from the lead with most critical changes in ST section or from the selected lead.
On the background of the QRS complex, the lines showing the locations of the
measurement points are displayed.
– 12 averaged QRS complexes - section in which the averaged QRS complexes
from 12 leads are displayed and also the results of the ST section
measurements (level, inclination).
– ECG recording parameters - in this line all information regarding the ECG
recording are displayed. These are, successively:
o amplification ( 2.5mm/mV, 5mm/mV, 10mm/mV, 20mm/mV ),
o move ( 25mm/s, 50mm/s, 100mm/s )
o muscular filter (25 Hz or 35Hz)
o mains filter, 50Hz,
– ECG recording window - section of the screen, in which the recordings of the
ECG test are displayed.

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Upper console

ECG recording Averaged QRS

window

Averaged x12

Recording
parameters Lower console

Figure 25. Stress test window

Description of the upper console

In the upper part of the screen, the line with the description of the actual test is
displayed - it is so called upper console. Below is the general view of the console,
when the treadmill and the cycle-ergometer are connected to the system.
Description of Duration of Duration of Velocity Treadmill Actual Bar METS Number Blood
the phase and the stress the actual of the inclinatio heart rate chart of value of Pressure
stage of the test stage [m:s] treadmi n angle frequency the HR detected and
stress test [m:s] ll [km/h] [%] VE/min Double
Product

Load of the
bicycle [Watt]

Attention: After pressing <F1> button (Help) on the right side of the console, the
menu will be displayed showing several commands allowing e.g. display of the
patient data window, preferences window or information about the program version.

The velocity of the treadmill is displayed in [km/h], and the inclination angle in [%].
The value of the given load for the cycle-ergometer is displayed in [Watts]. Duration
of the individual stages is displayed in minutes and seconds [m:s]. The value of the
measured blood pressure is displayed in [mmHg]. The Double Product is the ratio of
the systolic pressure and frequency of the heart rate measured during pressure
measurement, it is displayed in [mmHg*bpm].

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Description of the lower console

The user can control the test by using the buttons displayed in the lower console.
Each button is associated with the function keys on the computer's keyboard
(description on the button). Thanks to this, the user during the test can quickly enable
the specific function of the program.

The general view of the lower console is represented on Figure 26.

Figure 26. Lower console

Figure 27. Lower console

Before the beginning of the stress test, the lower console will look according to
Figure 27. On the left side, as the first one, is displayed [Start] button associated with
<F2> key on the keyboard. It is used for starting the stress test - rest or stress stage.
At the time of starting the stress stage, realization of the selected test report is
activated and the lower console will look according to Figure 27. In the place of
[Start] button, the [Manual] button will appear that is used for the control of the test.
After selecting this button, the small window will be displayed on the screen that
allow to change the load on the device and select next or previous stage of the test.

The [Menu] button allows quick access to the advanced options of the CardioTEST.
After selecting this button on the screen, the menu will be displayed that allows to:
– overview the actual patient data,
– overview of the realized protocol,
– start of the Online trends module,
– start of the Module Preview for the recorded already ECG signal,
– enter any commentary associated with the performed test.
–

Figure 28. Extension of the menu button

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Description of the other buttons:

– ESC - cancel the alarm associated with the ventricular arrhythmia detection,
– F2 Start - starts the stage or phase of the test,
– F4 Stop - stops the stage or phase of the test,
– F5 Pause - allows to stop the ECG run on the screen,
– F6 1mV - 1 mV calibration impulse and correction of the isoelectric line location,
– F7 Events - allows to enter the marker in recorded ECG along with the printout,
– F8 Event - allows to enter the marker into the recorded ECG,
– F9 Screen X - allows to select the ECG display mode,
– F10 Group X - allows to change the group of the leads displayed on the screen,
– F11 Lead - allows to select the particular leads displayed on the screen,
– F12 Pressure - enter the measured pressure,
– Exit - allows to end the test.

Description of the ECG recording window

The main part of the screen is designated for presentation of the real ECG course of
the test for the patient. Taking into consideration the diagnostics requirements, the
ECG signal can be draw in several modes (3, 6, 12 leads). Figure 29 presents
different modes of the ECG drawing depending on the user requirements.

Mode 1. Preview of 3 selected leads Mode 2. Preview of 6 selected leads

Mode 3. Preview of 12 selected leads Mode 4. Preview of 12 selected leads

Figure 29. Modes of ECG course presentation

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To change the manner of the display user must press the [F9 Screen X]. button. In
case, when on the screen presented is less than 12 leads, the [F10 Group X] button
allows to change the leads group defined earlier. The [F11 Lead.] button allows to
select the particular leads presented on the screen.

The channels selected to the detection and morphology determination

On the left side of the ECG signal window, the names of the
channels are presented (e.g. V1, V2). Additionally, available
are channels selected for the detection of QRS complexes (in
other words to the detection) by displaying in the rectangular
on the white background. The channels used for the
complexes morphology determination are displayed in the
rectangular on the red background. If the channel was
selected for the detection and determination of the
morphology it is displayed as the combination of the
described methods - in the rectangular on the white
background (e.g. detection) and on the red background (e.g.
morphology).

- channel selected for the detection of QRS complexes

- channel selected for the determination of QRS morphology

Figure 30, Selected
channels. - channel selected for the detection and the morphology

- channel not used for detection and morphology

Remember!

Choice of the channel for detection determines the correctness of the heart rate
determination. Therefore, the user should chose the channels for which the
signal is most stable (no isolines float) and which has less interferences.

The channels used for the detection of the morphology are selected in the similar
way. Additionally, the user must take into consideration that for the usage of the
leads system, in certain channels the ventricular complexes are poorly or almost
totally invisible. These channels are not used.

To change the channels for the detection and morphology, press the right button of
the mouse in the ECG recording window. The dialog window will be displayed on the
screen, that allows to select other channels. The selected channels will be used only
for the actually performed test. For the next test, the channels defined in the
preferences will be used again.

12 averaged QRS complexes window

During the stress test, the CardioTEST program constantly monitors any changes
that take place in the ECG recording. Evaluated are the parameters, such as heart
rate and level and inclination of the ST section. The results of the measurements are
presented on-line in the selected part of the screen. For each of 12 leads, the
following parameters are presented:
– name of the lead,

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– averaged QRS complex with marked measurement points,

– ST section level and inclination measurement results

If the measurements results exceed the limiting values, then the QRS complex is
displayed in the red colour. The leads that are excluded from the evaluation are
displayed in the gray colour.

ST level is expressed in [mm] in relation to the isolines, and the inclination in [mV/s].

Figure 31. 12 averaged leads window

Available functions:

1. Excluding the selected leads from the evaluation.

Point the cursor on the lead and press the right button. The colour of the
QRS will change and the particular lead will be excluded from the evaluation.
Press the right button again to include the particular lead in the evaluation.

2. Selecting the lead for the presentation in the window with single
averaged QRScomplex.
Point the cursor on the particular lead and press the right button.

Window of the single averaged QRS complex

To increase the accuracy of the evaluation, the averaged QRS from the selected lead
is presented in magnification. On the background of the averaged QRS complex, the
rest stage complex is displayed what allows the quick comparison. Except the ECG
recording, following parameters are displayed in the windows:
– name of the lead,
– ST level measurement in [mm] and ST section inclination in [mV/s], actual and
in the rest stage,
– measurement points,
– distance between J point and ST measurement point,
– mode of the lead selection,
– calibrating impulse 1mV.

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Figure 32. Averaged QRS complex window

Available functions

1. AUTO/MANUAL operation modes

In the AUTO mode, the lead, in which the most critical changes of the ST section
occurred, is automatically displayed in the window. If, in the window with 12
averaged complexes the other lead will be selected, then it will be displayed in
magnification for a few seconds. When the AUTO mode will be disabled, the lead
selected in the window with 12 averaged stimulations will be displayed in the
window.

2. Setting the measurement points

Method 1. Point the cursor on line of the measurement point. Press the left button
of the mouse and drag the line to the proper position and pull it.

Method 2. Select the [ST points] button, the dialog window will be displayed on
the screen with information about the number of the measurement points. Insert
the new parameters. Select [Apply] button.

Remember! During the stress test, the width and shape of the QRS complex
can be changed, e.g. together with the changes of the heart rate or with other
disorders. Location of the ST measurement points in this case should be
corrected to place the them in the proper places of the QRS complex. Therefore,
the CardioTEST © ASPEL program provides the mechanisms allowing to
perform this operation to provide the high accuracy and reliability of the
measured parameters.

Personnel that operates the system during the stress test is responsible for the
constant monitoring of the ST measurement points location. If, the
measurement points are placed in the incorrect positions, they should be
corrected according to the instruction described above. This will allow to
provide the correct ST values and correct evaluation of the stress test.

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4.2.1. Starting the stress test

After starting the Stress Test Module, the program continuously will be displaying the
ECG signal. Using the [F2 Start] button, we can start the test. The name of the stage
will change its name, and from now the ECG signal is recorded in the archive. The
system performs the test according to the selected report.
The whole report consists out of three parts: rest test stage, stress test stage (Bruce,
Balke, Cornell) and regeneration stage, in other words - post-stress test. The type of
test can be set in the program preferences (see chapter 7.2.5).
Before the test will start, the user can with the [F2 Start] button and pressing the
[F3 Stop] omit the rest test stage or one of its elements and move to the next stage.
However, please remember, that the rest recording is very important, because it
allows to determine the averaged QRS complexes that will be constitute the
reference point for the whole test.

4.2.2. Manual control of the device

CardioTEST (c) ASPEL program provides the manual control of the load for the
treadmill and cycle-ergometer during realization of the selected test report.
After starting the stress stage, in place of the present [F2 Start] button, new [Manual]
button will appear. This button is used to enable the manual control mode. After
starting this mode, the Manual control window (Figure 33) will be displayed on the
screen.
The value of the load can be changed by entering the correct value in the dialog
window or it can be set using the up and down arrows. User can also enter new load
by using the mouse with the wheel. To do this, place the cursor in the right window,
and then using the wheel set a new value. Entering of the value is performed after
pressing the <ENTER> button on the keyboard or [Apply] button.
When the Manual control window is enabled, the new stage is started. This stage is
named and described on the screen and on the prints as [Manual]. Closing the
Manual control window allows to return to the stage that could be realized, when the
window could not be enabled.
The value of the set velocity is expressed in [km/h], inclination in [%] – for the
treadmill and for cycle-ergometer in [Watts].

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Figure 33. Manual control window

The value of the load that is set after closing the Manual control window depends on
several factors. The main rule that applies in this case is as follows: „as long as the
load value set by the operator is higher than the value resulting from the selected
report, such value will be set and obligatory. Only when the load value set in the
report is higher than the value set, the realization of the report will start".

The figure below represents this rule:

During the stage 2, the manual control mode was disabled and set for the new load
value (red line, thin). This value is obligatory until the end of the stage 3, because it is
higher by the whole time from the report load value. From stage 4, the report value is
already higher and the full realization of the report is performed again.

Second situation - the load value set by the operator applies only until the end of the
actual stage (stage 2), because stage 3 has already the higher value.

In case of the treadmill control, we can change two parameters: velocity and
inclination. In such situation it is sufficient, that one report value will be higher than

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the set value, and the control function will come back to the full realization of the
report.

By viewing the test in the Test overview module, each call of the manual control is
described as the new stage and it is called as "Manual". Also the names that appear
on the printouts are the same. The manual control window can be also enabled
during regeneration stage. In this way, the operation of the last test stage can be
modified.

4.2.3. Online trends module

CardioTEST (c) ASPEL program is equipped with very modern and advanced
module for presenting the trends, histograms and charts for many different
parameters at the time of conducting the stress test - e.g. Online trends module. As
so far as the test is performed and more new data is collected, Trend Online module
is automatically updated and presented on the screen. Online trends module is
associated with Overview of the recorded ECG module. This module co-operates
with the trend and allows to return to any time of the recorder ECG signal -
simultaneously in the lower part, the actual recording is traced and presented. When
the alarm or arrhythmia will be present, the user will be informed about the situation,
to not skip any threads. The following Figure presents the preview of the window with
enabled Online trends module and Overview of recorded ECG module.

Online trends module

Overview of the ECG rerecorded

module

Actual ECG window

Figure 34. Stress test window with Online trends module

Online trends module is available only after the start of the stress test - earlier it
cannot be started. To display the module on the screen, press the [Menu] button that
is placed in the lower console of the window or use defined shortcut key <T> on the
keyboard. To hide the trends window, press the <T> key again.

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Types of presented trends and histograms:

Online trends module can present several trends and histograms:

– Heart rate trend,
– RR interval trend,
– trend of the load given on the cycle-ergometer or the treadmill,
– MET trend,
– ST trend - high and low ST values, ST section inclination and Delta ST,
– J trend – locations of the J point and Delta J,
– histogram from the detected SVE and VE complexes,
– measured pressure values chart (in the form of blood pressure bars).
To facilitate the usage of the trends, some sets of the trends were defined, that can
be selected for the presentation on the screen. In the upper right corner of the Online
trends module includes the button that allows to change actually presented trends.
After selecting this button, the window dialog with predefined sets will appear on the
screen.

Figure 35. Chart selecting window

Elements of the trends window

Example of the trends module window is presented below (HR and level ST + Delta
ST options are selected). The horizontal axle represents the actual time of the
performed test. The vertical axle on the left side represents the scale for HR chart,
and on the right side the scale for ST chart. The colours are used for the
differentiation of the represented curve, that is described by the legend located on
the right side of the window - brown colour represents HR trend, red colour ST trend
and blue colour Delta ST trend. The trends module window provides also the cursor
that can be moved on the chart. The actual location of the cursor and valued read
form the charts are described on the white field. In case of the ST trends, on the right
side of the module, there is the possibility to chose the lead type that we want to
view.

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Button for selecting the trends

Trend cursor
Change of the lead

The next two examples present general overview of the Online trends module
window after selecting the proper location
– SVE and VE histogram,
– Blood pressure chart.

In both cases, after placing the cursor over the selected bar, within the frame on the
yellow background the read chart parameters are presented. For the Histogram this a
number of the over-ventricular and ventricular complexes in the given time range,
and for Blood pressure chart it is the pressure value (systolic and diastolic) for the
selected measurement.

The color scheme for the Online trends window can be changed according to own
preferences in the program settings. More information about this subject can be
found in chapter 8.3.1 Configuration of the displaying method.

4.2.4. Overview of the recorded ECG module

The module of the overview of the recorded ECG allows to view this part of the signal
that is already recorded by the system, despite that the patient is still monitored and
its signal is presented on the screen in the separate window. In this way the user can
go back to the any time of the test, and continuously tracing the records and
comparing them with the earlier signal.

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Figure 36. Recorded ECG overview window

Recorded ECG overview module is available only after the start of the stress test -
earlier it cannot be enabled. To display the module on the screen, press the[Menu]
button that is placed in the lower console of the window or use defined shortcut key
<V> on the keyboard. To hide the trends window, press the <V> key again.

Controlling module operation

Controlling of the module operation is done by using the buttons located on the lower
console of the program:
– [F9 Screen] – settings for the required number of channels needed to display,
– [F10 Group] – settings for the required leads group,
– [F11 Lead] – selection of the required leads using the dialog window.
These buttons differ from the other buttons located in the lower console by usage of
the double frame, because they have the double role. By using these buttons, the
user can change the settings of the Recorded ECG overview module and Actual
ECG module. However, they allow to change only the operation parameters for the
actually selected module. Actually selected module is always marked with the pink
frame around its window. To change this setting, click once the area of the given
module, and the frame will be redraw. Additionally, the user can also change the
speed of the ECG signal drawing (25 mm/s, 50 mm/s, 100 mm/s) and the signal
amplitude scale (5 mm/mV, 10 mm/mV, 20 mm/mV).
Recorded ECG overview module describes each detected QRS complex through:
– location of the detection point,
– morphology determined by the program (D-dominant, V-ventricular, N-not
determined),
– heart rate value between the complexes.
The actual time and the stage description of the stage is displayed in lower part of
the module window. By using the buttons <Left arrow> and <Right arrow> on the
keyboard, the user can move to the another fragment of the test.

Other used keys:

[Enable/Disable] <V>
[Beginning of the <HOME>
record]

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[End of the record] <END>

[Next page] <PgDn>
[Previous page] <PgUp>
[1 second to the left] <Left arrow>
[1 second to the right] <Right arrow>
[Drawing speed] gray +/- (left/right arrow allows to move on the strip by
1 second)
[Signal amplification] <Up/Down arrow>

Co-operation with trends module

Recorded ECG overview module co-operates with the Online trends module. By
changing the location of the cursor in the Online trends module, the content of the
Overview nodule is automatically changed, to represent the ECG signal for the same
period of time. In such way, by using the Trend module the user can quickly find the
interesting fragment, e.g.:
– distinct ST decreasing,
– steep increase of the heart rate,
– area with large number of the ventricular beats,
– other events.

Please remember, that such connection is done only in one way, e.g. when the trend
cursor is changed, the content of the Recorded ECG overview module is also
changed. Changing the content of the Overview module, e.g. by using the arrow
buttons, the location of the trends is not changed.

4.2.5. Blood pressure measurement

The Blood Pressure Measurement Module allows you to enter the pressure
measured by the operator and to measure the pressure automatically via an external
pressure unit.

Show list

Add measurement

Pressure input fields

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By pressing the <F12 Pressure> button, which is located on the lower console of the
stress test window, a dialog box will appear on the screen, which allows you to enter
the measured pressure or perform an automatic measurement.

To enter the pressure measured manually, enter it in <Pressure input fields>, then
press <Enter> or the <+> button. This value will be displayed on the top console.

4.2.6. Ending the stress test

Decision about the ending of the stress test is done by the physician who is
performing the test. Press [F4 Stop] button. The message asking for confirmation will
be displayed on the screen.

Figure 37. Confirmation of the test ending

By pressing the <ENTER> key or [YES] button the user can move to the stress
stage. Duration of the stress stage is not limited. When the physician makes the
decision about ending the post-stress stage, the [Stop] button is pressed. The "Test
report" window will be displayed on the window that allows to enter the test
description and select the element for printing.

Figure 38. Summary of the post-stress test window

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In the defined fields the user can enter the description regarding:
– reason for interrupting the examination,
– evaluation of ST section,
– stress test interpretation.
The test report consists of several sections. Depending on the requirements, the
printout can contain:
– pages with patient data together with the test summary,
– pages with the trend charts for the changes in ST section,
– printouts of the averaged P-QRS-T complexes printed according to the defined
plan,
– table with numerical measurement results for ST section level and inclination,
– raw ECG printouts according to the defined plan,
– printouts of ECG fragments marked as the events by the operator in the
program.
– the printouts of ECG fragments are marked as detected arrhythmias.
The button with description [...] allows to change the printing plan.
By confirming using the [OK] button, the user can automatically print the selected
elements of the report. Positions with marked selection fields are designed for
printing. By using [Printout] button they will be printed on the default printer in MS
Windows system. When [Cancel] key is selected, no action regarding the printing is
performed – the test will be saved in the database, and the window will be closed.
The report printout can be repeated or printed first time using the 'Test overview
module'.
The analysis report can also be saved as a PDF file. This can be done by pressing
the <PDF> button.
Other tabs: [ECG strip] and [Leads] are used for selection of print parameter
connected with the printing of the recorded ECG signal – e.g. graph paper type, print
speed, number and types of the leads.

Figure39. Printout Preview Module start-up window

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The sheet also contains a <Preview> button. After pressing this button, on the
screen will appear a new window. From this place you can start the Printout Preview
Module that allows to see how specific report section will look. The <...> buttons work
similarly to the ones in the Analysis report window.

4.2.7. Report preview module

The preview module provides the appearance of the selected print element on the
screen. If the printout consists of several pages, the next or previous page can be
viewed by pressing [Next Page] and [Prev Page] buttons. On the viewed page, in
the upper right corner, there is a information about the page that presented right now
(e.g. 2/4 – two of four). There is possible also the printed pages preview mode
[Two Page] - two pages are displayed on the next to each other. [Increase] and
[Minimize] buttons are used for maximization and minimization of the displayed
actually page. Return to the main window is performed by pressing the [Close]
button or <ESC> key on the keyboard.

Figure 40. Print preview module

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5. Browsing the recorded tests

All test performed with using the CardioTEST (c) Aspel program are saved in the
archive. By selecting the [Examinations] button in the main window, the user can
open the window that will allow to browse the tests for the selected patient. The
examinations browsing is performed by using two main modules: module that
presents ECG signal in different configurations and module that presents the test in
the form of trends, histograms and charts. Below we present the program window
that is displayed on the beginning after moving to the test preview mode.

Figure 41. Test browsing window in the strip mode

5.1. Browsing the ECG signal

The Test Browsing Module allows to browse ECG signal in two modes: Strip and
Page.

– The Strip mode provides the preview of 3/6/12 selected ECG signal leads on
the screen with the rate of 25mm/s, 50mm/s or 100mm/s (in other words 16, 8,
4 seconds on the full screen).
– The Page mode provides the preview of the full test, selected lead on one
screen – per 1 (one) minute in the line. The switching between these modes is
done by the [Page/Strip] button - F8 keyboard on the keyboard.

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Description of the lower console in Strip mode

The lower console provides the preview of the recorded tests.

Figure 42. Lower console

Description of the lower console function:

– << - back to the beginning of the test,
– < - previous strip,
– > - next strip,
– >> - back to the end of the test,
– F8 Page - change the display mode,
– Trends - enable Trend module,
– F9 Screen xx - select the number of displayed leads,
– F10 Group X - select the lead group,
– F11 Lead - individual selection of the leads,
– F12 Printout - ECG printout,
– Report - report printout,
– Return - end of test preview.

Description of the lower console in page mode

Selection of the lead Change Change Printout Printout Close
Amplifications of mode ECG of the the module
report

Figure 43. Lower console in Page mode

Description of the upper console

Tests list Event list (operator's + arrhythmias) Realization Help

Figure 44. Upper console of the Test module

Test list contains all tests for the selected patient. Each test has a consecutive
number, recording date and duration time. Button marked as [-] allows to delete the
test from the archive. [...] button provides preview and edition of the information
about the particular test.

Event list consists of markers entered by operator and events recognized by the
program as ventricular arrhythmias. To differentiate two types of the arrhythmia, the
following convention was accepted:
– operator events are always placed on the beginning of the list, and their number

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is placed within brackets. In the Strip mode, the events on the screen are
marked with: marker, and in Page mode with the navy blue dot.
– events connected with ventricular arrhythmia detection are placed below, and
their number in placed within the square brackets. In the Strip mode, the events
on the screen are marked with: marker, and in Page mode with the navy blue
dot.

To move to the next event, the user can select the event from the list and then press
the WHITESPACE key. Another pressing of the button allows to move to the next
arrhythmia. There is also the possibility to add the new event (both, the operator
event and arrhythmia), delete the event selected form the list and edit the information
about such event. In case of the edition of the operator event, this will be the edition
of the description, and in case of the arrhythmia, this will be the type of the defined
arrhythmia.

[Reanalysis] – this button allows to perform another analysis of the stress test (see
details: chapter 6). [Help] – this button enables the Menu that allows access to the
Patient database, Preferences and information about the program (e.g. version
number).

Selecting the ECG fragment for the print in 'Page' mode

There are two ways for selecting the fragment designed for the printing. First one is
performed by setting the frame that is available in the screen, in this mode in the
proper place of the test (the arrows buttons are used as standard to move the frame).
The second one is performed by marking the area designed for printing using the
right button of the mouse. After pressing the right button of the mouse, the small
frame will appear on the screen that can be resized by moving the mouse (with
pressing left button of the mouse).

Examination report

From the level of analysis review it is possible to create an analysis report. After
pressing the <Report> button on the lower console of the Analysis Review Module
on the screen will appear a window that allows to adjust settings concerning the
report.

In the <Printout> tab you can implement analysis description and elements that the
report should contain.The <...> button allows to implement printout plans

In the <ECG strip> tab are located settings concerning the strip printout, such as
page layout and the speed of printed ECG signal. In the <Leads> tab you can select
which and how many leads should be printed.

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To print the report, press the <Printout> button. The report will be printed out by the
default printer of the MS Windows system.

Figure45. Examination report printout window

It is also possible to save the report as a PDF file. For this purpose please press the
<PDF> button. The “report.pdf” file is saved in database in a folder, in which the
given analysis is contained. After the creation, the report file will be opened in the
default PDF file viewer. When creating a next PDF report for a given analysis,
subsequent elements will be added to the previous report. The previous report is not
deleted. The PDF report file can be opened or deleted from the level of patient data
window and from the Analysis Review module from the menu opened using the
<F1 Help> button.

The <Examination report> window also allows to preview the report. For this
purpose press the <Preview> button. On the screen will appear a window in which
you can select the section of report to show.

To close the window without taking any action, press the <Close> button.

Strip printout

In order to printout a strip, press the <F12 Printout> button on the lower console of
the Analysis Review Module. On the screen will appear a window that allows to
adjust printout settings. In the <Basic> tab you can set the time and moment of
beginning of printed ECG signal, as well as the printout mode. In the <ECG strip>
tab are located settings concerning the strip printout, such as page layout and the
speed of printed ECG signal. In the <Leads> tab you can select which and how
many leads should be printed.

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Figure46. ECG Strip printout window

To print the given fragment of the ECG Strip, press the <Printout> button. The Strip
will be printed out by the default printer of the MS Windows system.
It is also possible to save the Strip as a PDF file. For this purpose please press the
<PDF> button.

Key shortcuts in Test module

General keys:
[-] (delete test) <DEL>
[...] (about the test) <INSERT>
[Patient] <Alt + P>
[Preferences] <Alt + R>
[Page\Strip] <ENTER>
[Next events] <WHITESPACE>
[F1...F11] according to the console description
[Return] <Z>

Strip mode:
[Beginning of the test] <HOME>
[End of test] <END>
[Next page] <PgDn>
[Previous page] <PgUp>
[1 second to the left] <Left arrow>
[1 second to the right] <Right arrow>
[Rate] only gray +/- (left/right arrow allows to move
on the strip by 1 second)
[Amplification] <Up/Down arrow>

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ECG page mode:

[Amplification +] <gray +>
[Amplification -] <gray ->
[Move the frame] <Up/Down, Left/Right arrows>
[Lead] keys from <1> to <=> respectively I, II, III, aVR, aVL,
aVF, V1 ...V6

Time-amplitude measurements
During the overview of the tests, there is the possibility to perform the measurements
of the amplitude and time distances.
Amplitude measurement:
– Point the cursor on the first measurement point.
– Press the <Shift> key and simultaneously press the left button of the mouse.
– Move the cursor over the second measurement point.
The vertical line will appear on the screen that ended with the arrows pointing to the
measurement points, the measurement result in [mm] is displayed next to this line. If
we point the cursor of the mouse to the middle of the line, then after pressing the left
button of the mouse we can move the measurement line to the new position. By
pointing the cursor if the mouse to the ends of the line in the same way, the user can
change the length of the measurement line.

Time measurement
– Point the cursor on the first measurement point.
– Press the <Ctrl> key and simultaneously press the left button of the mouse.
– Move the cursor over the second measurement point.
The horizontal line will appear on the screen that ended with the arrows pointing to
the measurement points, the measurement result in [ms] is displayed next to this line.
If we point the cursor of the mouse to the middle of the line, then after pressing the
left button of the mouse we can move the measurement line to the new position. By
pointing the cursor if the mouse to the ends of the line in the same way, the user can
change the length of the measurement line.

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Editing the QRS beats

During the test and recording the ECG signal in the archive, the ECG analysis is also
performed that provides differentiation of the QRS complexes and defining their
origin, in other words - the morphology. This information can be viewed during the
realization of the stress test in Recorded ECG overview module and during the
overview performed after the test in the Test Browsing Module.

Each QRS complex is described by:

– location of the detection point (the short vertical line near the peak of the
complex in the first channel),
– morphology determined by the program (D- dominant, V- ventricular, N- not
determined),
– heart rate value between the complexes.

Additionally, the complexes with ventricular morphology ‘V’ are marked with red color
(keeping the default settings), and the complexes that were not qualified by the
program are marked with the gray color and described by ‘U’ letter (unknown) .

The user of the program in case of the ‘U’ complexes must evaluate by himself,
whether it is the QRS complex with morphology or it is a disturbance. Therefore, the
Test Browsing Module can be used also for edition of the beats, e.g. deleting the
QRS complexes, adding the missing ones and change the morphology.

Adding the QRS complexes

Adding the QRS complex can be performed only in the Strip mode. To add QRS,
place the mouse cursor over the ECG signal area on the strip, and then press and
hold the right button of the mouse. The vertical line will be displayed on the screen
(e.g. cursor) that will point the place to which the complex will be added. To change
the place, holding the pressed right button of the mouse move the mouse to the left
or right side. After placing the cursor (usually on the R peak of the QRS complex that
was not detected), release the right button of the mouse. The dialog window will
appear on the screen that will allow to define the morphology of the added complex.
After selecting the proper key, the QRS complex will be added, and the description of
the new complex will appear on the screen.

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Deleting the QRS complex

Deleting the QRS complex can be performed only in the Strip mode. To delete the
complex, place the mouse cursor over the letter describing the morphology of the
QRS complex (upper part of the Test Browsing Module window), and press the left
button of the mouse. The vertical line will be displayed on the screen (e.g. cursor)
that will point the deleted complex. Then, press <Delete> button on the keyboard and
confirm the operation. The complex will be deleted, and the description of the QRS
complex will disappear.

Changing the QRS complex morphology

Any changes in the QRS complex can be performed only in the Strip mode. To
change the morphology of the complex, place the mouse cursor over the letter
describing the morphology of the QRS complex (upper part of the Test Browsing
Module window), and press the left button of the mouse. The vertical line will be
displayed on the screen (e.g. cursor) that will point the complex. Then, press <D>,
<V> or <N> key on the keyboard (shortcuts of the available morphologies), and
confirm the operation. The morphology of the complex will be changed, and the QRS
complex description will be displayed on the screen.

5.2. Browsing trends, histograms and charts

Browsing the saved test by using trends, histograms or charts is performed in the
Trends module. To enable the Trends module on the screen, press the [Trends]
button that is placed in the lower console of the window or use defined shortcut key –
<T> on the keyboard. To hide the trends window, press the <T> key again. After
enabling the module, the screen will be divided on the two parts. The Trends module
will be displayed in the upper window, and the module for browsing the ECG signal in
the lower part.

Online trends module

ECG browsing module

Figure 47. Test window with Trends module

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Types of presented trends and histograms:

The Trends module can present several trends, histograms and charts:
– Heart rate trend,
– RR interval trend,
– trend of the load given on the cycle-ergometer or the treadmill,
– MET trend,
– ST trend - high and low ST values, ST section inclination and Delta ST,
– J trend – locations of the J point and Delta J,
– histogram from the detected SVE and VE complexes,
– measured pressure values chart (in the form of blood pressure bars),
– ST 3D chart – ST level for all test channels.

To facilitate the usage of the trends, some sets of the trends were defined, that can
be selected for the presentation on the screen. In the upper right corner of the Trends
module there is available the button that allows to change the actually presented
trends. After selecting this button, the window dialog with predefined sets will appear
on the screen.

Figure 48. Chart selecting window

The predefined complexes were divided on the 3 parts. The first two parts allow the
selection of max. two charts on the screen, and the third part allows to select only the
ST 3D chart. After setting the required configuration, confirm the selection by
pressing [OK] button.

Elements of the trends window

Example of the trends module window is presented below (HR and ST level options
are selected). The horizontal axle represents the actual time of the performed test.
The vertical axle on the left side represents the scale for HR chart, and on the right
side the scale for ST chart. The colors are used for the differentiation of the
represented curve, that is described by the legend located on the right side of the
window - brown color represents HR trend, red color ST trend and blue color ST

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level. The trends module window provides also the cursor that can be moved on the
chart. The actual location of the cursor and valued read form the charts are described
on the white field. In case of the ST trends, on the right side of the module, there is
the possibility to chose the lead type that we want to view.

Trend cursor Change of the lead

The next two examples present general overview of the Online trends module
window after selecting the proper location:
– SVE and VE histogram,
– Blood pressure chart,

In both cases, after placing the cursor over the selected bar, within the frame on the
yellow background the read chart parameters are presented. For the Histogram this a
number of the over-ventricular and ventricular complexes in the given time range,
and for Blood pressure chart it is the pressure value (systolic and diastolic) for the
selected measurement.

The color scheme for the Trends window can be changed according to own
preferences in the program settings. More information about this subject can be
found in chapter 8.3.1 Configuration of the displaying method.

3D trends

3D (3-dimensional) charts provide the large presentation possibilities in the

diagnostics. The allow to present on the screen great number of the data in the
readable and clear way.

ST 3D chart in the Trends module has the possibility to present any changes on the
ST content that took place during the whole test for all channels. In this way, the

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program creates the pleated surface that thanks to its shape provides information
about the test.

ST value for
cursor position

Chart cursor

All plateaus on such surface should be treated as the areas of the ST decrease, and
peaks as the ST increase. The colors marked on this surface provide the general
information about the magnitude of the changes (according to the legend located on
the right side of the chart).

Chart axis . The vertical axis provides the ST values scale. The other two axes
provide: Y axis - test time moment, and Z axis - presentation of the data from the
particular channel.

Cursor. The accurate ST value for all channels can be read from the table located
above the chart. This table represents the value read from the position of the cursor.
The cursor on the 3D chart is in the form of the broken line placed on the surface. It
can be moved by moving the mouse. The chart cursor is placed by the movement of
the mouse.

Filtration. Data connected with the ST value before are displayed on the screen are
initially filtered to eliminate all eventual incorrect values and to even any temporary
changes. Any regulations of the filtration degree can be performed on the right side
of the 3D chart, form the lowest degree (A) to the greatest one (C).

Changing the chart inclination. By using buttons the user can change the
inclination of the chart, in other words he can turn it to right or left side. In this way
the user can "see" more clearly some areas of the surface. This option is very useful
in situation, when the surface contains several increases that cover the other data.
After turning the chart, all data are visible.

Amplification. There is the possibility to change the amplification of the signal, in

other words the vertical scale. This option also is very useful in the interpretation of
the analysis results.

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Printing. The content of the screen (3D ST chart) can be printed in the form of the
actually presented on the chart (with actually set amplification, inclination). The
printout on the printer is performed in form of the grid, without any colors. To make a
print, press the [Print] button placed on the right side of the chart.

Co-operation with ECG overview module

The Trends module is connected with ECG signal overview module. By changing the
location of the cursor in he Trends module, the user can automatically change the
content of the ECG overview module in such way, that the ECG signal will be
presented in the same period of time. In such way, by using the Trend module the
user can quickly find the interesting fragment, e.g.: ST decrease, strong increase of
the heart rate, area with large number of the ventricular beats, or other events.

Please remember, that such connection is done only in one way, e.g. when the trend
cursor is changed, the content of the Recorded ECG overview module is also
changed. Changing the content of the Overview module, e.g. by using the arrow
buttons, the location of the trends cursor is not changed.

5.3. Exporting the analysis results

CardioTEST (c) Aspel program provides the export function of the all analysis results
for further processing by using other programs, e.g. MS Excel. The export function is
available in the menu that is displayed after pressing the [F1 Help] button. The [Help]
button is located on the right side in the upper console of the program.

All exported data are saved in the text file in the location defined by the user. The
below example presents all information included in the file:

Name: Adamsom David Time – time of QRS complex detection in the

format: gg:mm:ss::millisecond.
Address:Gardiner Street Lower
DetPt – detection point. The number of the
Inner City Dublin sample from the beginning of the test, where the
QRS complex was detected.
Time: DetPt Morf RR
=================================== Morf – QRS complex morphology. Available
morphologies: D, V, U (unknown).
12:26:00:1398 179 D 820.00
12:26:01:820 505 D 815.00 RR – RR distance, a distance between two
12:26:02:203 826 D 802.50 adjacent complexes expressed in milliseconds.
12:26:02:2734 1150 D 810.00

The above saving format allows the easy way to transfer this data to the other
programs, e.g. MS Excel and to generate own trends, charts, histograms, statistics,
comparisons, calculate own factors that will be useful during the test evaluation.

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6. Reanalysis of the recorded test

All test performed with using the CardioTEST program are saved in the archive. The
Tests module allows to browse the particular test, generate the report and re-analysis
of the test. By selecting the [Examination] button in the main window, the user can
open the window showed below.

The button that provides

the function of the re-
analysis.

Figure 49. Test overview window

The [Reanalysis] button allows to perform another analysis of the test with different
settings influencing the results. CardioTEST program allows to change the following
parameters:
– main and auxiliary channel used for the detection,
– channels selected for the determination of QRS complexes morphology,
– number of the averaged evolutions to determine the actual HR and the average
complex,
– location of the ST – BL, J, ST measurement points,
– defining ventricular arrhythmia,

After selecting the [Reanalysis] button, the dialog window will be displayed on the
screen that will allow to change channels used to the detection and classification.
During the time, when the dialog window is displayed on the screen, the program still
allows to use the button placed in the lower part of the screen, providing in this way
the browsing function for the test and selecting the best possible channels. After
pressing the [START] button in the dialog window – the re-analysis of the test is
getting started.

The channels for detection and classification can be changed also during the re-
analysis - to do this, just click the right button of the mouse on the area of the ECG
runs drawing. The ECG analysis parameters dialog window will be displayed on the
screen (see Figure 50). To change the location of the ST measurement points, press
the [ST points] button located in the averaged complex window or make the
correction of the points location on the averaged complex (for the detailed description

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see chapter 4.3 Electrocardiography stress test - One averaged QRS complex
window).

The designation of the ventricular arrhythmias can be enabled or disabled by using

the settings in the preferences (see chapter 8.3.1). Remember, that the correct
designation of the ventricular arrhythmias is influenced by the process of complexes
detection and the proper designation of their morphologies. If, the re-analysis is
performed to better designation of the ventricular arrhythmia, the user should select
for detection and classification such leads, that will provide the best detection of the
ventricular complexes.

ECG analysis parameters

changing window

Change of the ST
measurement pints
location

Figure 50. Test re-analysis window

To provide the full control for the operator over the re-analysis process, Aspel
created the [Reanalysis] module that allows to recreate the process of the tests
together with all details. The re-analysis module allows to:
– change analysis parameters before and during the analysis realization,
– watch the ECG curve runs in all 12 leads with possibility to change the
displaying mode (3, 6 leads on the screen), amplification, rate, filtration of the
signals,
– watch the QRS averaged complexes and actual location of the ST
measurement points,
– watch all the information about the detected arrhythmias.

To accelerate the re-analysis, the user can use [Speed] button that allows to change
the speed of the test reproduction. This allows to perform the re-analysis of the test
with possibility of the full preview within ca. one minute.

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In situation, when the operator will need to stop the re-analysis, he can use the [F5
Pause] button or <WHITESPACE> key on the keyboard. After making all needed
changes, he can continue the re-analysis by selecting again the [F5 Pause] button or
<WHITESPACE> key. The other buttons will have the same function as during the
stress test realization.

After finishing the reanalysis and selecting the [Exit] button, the program returns to
the Test Browsing Module and provides the overview and printing of the reports for
the recorded test together with the new analysis results.

In case, when the reanalysis is finished earlier by using [Exit] button, the program
does not save the new analysis results, e.g. it returns to the previous results,
because the re-analysis was not finished. The user of the program is not informed
about such situation with the appropriate message.

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7. Program configuration
CardioTEST program is very flexible. Therefore, each user can configure the
program according to his requirements. Main window of the program contains the
[Settings] button. This function of the program allows to change all parameters that
control the operation of the program.

7.1. Settings
By pressing the [Settings] button, the user can gain the access to the functions that
allow to configure the system.

Figure 51. Additional functions that allow to configure the program

All settings are divided on two man sections:

– [Preferences] - defining the parameters that control the program operation,
– [Data Base] - creation and configuration of the data base.

7.2. Preferences
The CardioTEST program has been designed in the such way, that each user can
define own (preferred) parameters for the control of the program operation. After
pressing the [Preferences] button, the dialog window will be displayed on the screen
(see Figure 52).

Figure 52. "Preferences" function dialog window

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This window contain many buttons that allow to select the specific group if the
defined parameters.
– [Ergometr] - type of exercise device and communication parameters,
– [BP] - type of pressure recorder and communication parameters,
– [ECG] - how the ECG recording will be displayed on the screen,
– [Stress] - parameters for controlling the stress test,
– [Report] - defining the appearance and content of the test report,
– [Settings] - user data, information about the monitor and processor,
– [Groups] - defining the lead groups,
– [Protocols] - selection of the existing test protocol or creating new,
– [New] - creating new preferences,
– [Delete] - deleting existing preferences,
– [Apply] - accepting the entered changes,
– [Cancel] - cancelling the entered changes.

7.2.1. Ergometr
For the proper operation of the program, it is very essential to define the ECG signal
source and the type of the treadmill or cycle-ergometer that co-operates with the
system: After selecting the [Ergometr] function, the dialog window will be displayed
on the screen. The window is divided on two parts. On the left side, there is a
possibility to select the type of the device for the ECG signal and defining the
communication port to which the device is connected. On the right side, we can
select the type of the treadmill or cycle-ergometer connected to the system, and also
the port allocated for these devices.
Selection of the correct device, that is mounted in the doctor's office and the proper
communication port to which this device is connected is necessary for the proper
functioning of the system. The [Test] button allows to control the settings. After
pressing this button, the program will check the device and displays the message
with results of the checking.

When AsPEKT 500 device will be selected as the device emitting the ECG signal, it
is not necessary to set for this device the communication port. We only have to enter
its unique ID that is given on the label attached to the device. AsPEKT 500 device is
communicating with CardioTEST program through the wireless communication using
BlueTooth adapter with USB port. The detailed information about the BT adapter
installation is available in chapter „BlueTooth adapter installation instructions for
Aspel system”.
For the treadmill, there is possible the additional button - [Go Up]. By using this
button, the treadmill is lifted ( inclination 25%). This allows to unscrew the transport
wheels that are available in some types of the treadmills (e.g. B612 Model C v.701)
and to make necessary maintenance actions.

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Figure 53. Dialog window for "Devices" function

7.2.2. Interaction with the treadmill equipped with the

inclinometer

The modern B-612 treadmill is equipped with the device that allows to automatically
levelling of the treadmill (inclinometer). Therefore, the loading of the device is much
more accurate. When the test is started, the program checks the range of the
inclination angle for the treadmill and whether is this angle sufficient for realization of
the test report. In case, when the necessary inclination angle cannot be obtained, the
message presented on the figure below will be displayed on the screen.

Figure 54. Message informing that the inclination angle of the treadmill is exceeded

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7.2.3. BP
CardioTEST program provides the possibility of automatic blood pressure
measurements according to the elaborated measurements plan. Automatic blood
pressure measurement system cooperates with the SunTech recorders. Such
recorders is connected to the computer through the RS-232 connection. The program
controls the recorders operations, says when the measurement should be performed
and allows to read the measurement results and store them in the database. In such
way, the operation of the program does not need manually performed blood pressure
measurements and entering them to the program.

7.2.4. Configuration how the ECG recording is displayed

By selecting the [ECG] button in the Preferences window, the dialog window will be
displayed on screen that allows to define the way how the ECG recording will be
displayed on the screen (see Figure 55).

Figure 55. Dialog window to define how the ECG recordings will be displayed

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The user can set the following parameters:

– number of displayed leads (3, 6 or 12),
– filters state (enabled/disabled),
– move ( 25mm/s, 50mm/s, 100mm/s )
– amplification ( 2.5mm/mV, 5mm/mV, 10mm/mV, 20mm/mV ),
– print mode after finishing the test (automatic/manual).
There is also the possibility to individual define the way how different elements of the
program will be displayed (colors). They are four main tabs:
– [ECG colours] - defining the ECG signal color, background, grid and VE
complexes color, etc,
– [QRS colours] - defining the colors of the averaged QRS complexes,
– [Trends Graph colours] - defining the colors of the trends, histograms, blood
pressure charts, ST charts,
– [Value colours] - defining the colors for HR value displayed in the upper
console, e.g. color of the Normal, Sub-Maximum and Maximum value.
After selecting these tabs, the picture of the selected program fragment and the
buttons allowing to change the particular colors for these elements will appear on the
screen.

7.2.5. Configuration of the stress test run

The CardioTEST program controls the whole process of the stress test using earlier
defined preferences. After pressing the [Stress] button in the Preferences window,
the window (see Figure 56) will appear that will allow to define all parameters that
control the operation of the system.

Figure 56. Stress test parameters window

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In specific fields the user can enter the data including:

– PMHR - percent of the maximum frequency of the target frequency rate,
– reports:
o rest stage report,
o stress stage report,
o post-stress stage report,
– monitoring of the blood pressure:
o on the end of each stage,
o every defined interval,
o automatic measurement,
– sound signalization.
Under the following tabs, we can configure the start values relating to:
– QRS analysis:
o channels for detection QRS complexes,
o channels for the determination of QRS complexes morphology,
o number of the averaged QRS evolutions to calculate HR
– ST analysis:
o location of the BL, J, ST measurement points,
o alarm values for the ST increase and decrease,
– Arrhythmia analysis - enabling or disabling the automatic detection of the
ventricular arrhythmias.

7.2.6. Report configuration

A report is the final result of the stress test. Content and form of the report depends
on the user requirements. By selecting the [Report] button on the Preferences
window, user can define the parameters that control the report printout process (see
Figure 57).

Figure 57. Report printout control parameters window

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There is the possibility to define:

– form of patient data print
o all or basic patient data,
o printout of the entered summary of the test,
– print direction - horizontally or vertically,
– paper type (normal/graph paper),
– type of the grid
o without grid,
o simple grid,
o full grid,
– ECG rate on the print
o 25 mm/s,
o 50 mm/s,
o 100 mm/s.

After finishing the stress test, there is the possibility to print the ECG and averaged
P-QRS-T complexes according to printout plan. By using [The plan of ECG strips]
and [The plan of QRS] tabs, user can open the window that allows to define the
frequency of this type of printouts.

Figure 58. Window for printing planning

The plan includes the prints in any stage of the test. There are three possibilities to
define the frequency of the printed fragments:
– on the end of each stage
– on the beginning of each stage
– every defined interval,

Other solution allows to plan the printing process according to the time of the test, to
not print the earlier fragments.

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7.2.7. Definition of the ECG lead groups

During the stress test, the ECG recording is displayed on the screen. Depending on
the requirements, there are displayed 3, 6 or 12 ECG leads. If the number of the
displayed leads is less than 12, the [F10 Group] button allows to quickly select the
displayed leads. The user has the opportunity to define the lead groups that will be
changed with pressing F10 key.

Figure 59. Lead groups definition window

7.2.8. User identification

The name of the office in which the test was performed is placed on the printed
reports. By pressing [Settings] button in the Preferences window, the window will be
displayed on the screen that allows to enter the user data.

Figure 60. Window that allows to enter user data

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The user data includes:

– name,
– address,
– other data, such as telephone number.

The entered data will be placed on the ECG prints and test reports.

7.2.9. Protocols

During the stress test, CardioTEST program controls the operation of the treadmill or
ergometer. Patient is the subject of the stress according to defined protocol. After
pressing the [Protocols] button in Preferences window, the user can select one of
the standards protocol or create its own protocol.

Figure 61. Dialog window for selecting the test protocole

Button functions:
– [+] - new protocol,
– [-] - deleting protocol,
– [m] - changing the name of the protocol
– [New] - entering new stage,
– [Insert] - insert a new stage,
– [Edit] - correction of the existing stage,
– [Delete] - deleting the stage.

The report can include up to 15 stages.

RAMP type report – by enabling this option, changing the load value on the device
is performed smooth between the stages.

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7.3. Database

Data Base function allows to create the archive in which the patient personal data are
stored and the results of his tests. In this way, each physician can has his own data
storage including only his patients or he can create separate data storages for all
served units and entities.

After selecting this option, the dialog window will appear on the screen that allows to
create and delete the data storages.

Figure 62. Window for defining data storages

The data storages can be created on any data carriers visible form the MS Windows
operating system level, such as disc (e.g. local discs, network discs, CD-RW and
others archiving devices). Always, only one data storage has "actual" status. This
data storage is by default selected in the patient data window. To change the data
storage, user has to select the particular data storage and press the [Current] key.

To add the new data storage, press [Add] button. The dialog window will appear on
the screen that allows to select any other place for storing the data. After selecting
thus place, in the lower part of the window, in the "Name" field enter the name of the
data storage and press OK button.

Deletion of the data storage can be performed on the two levels. The first level allows
to delete the shortcut to the data storage (item [ShortCut] in the menu in Figure 62).
After this operation the data storage will not be visible in the window, but it will be still
on the disc. The second level allows to delete the data storage from the disc. After
this operation all data will be erased form the disc and not accessible.

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Please remember, that this operation cannot be recalled and the deleted data
will not be recovered (this data is not available in the Recycle Bin of the
Windows operating system).

The Data Base window includes also the [Export] button. It allows to generate the
basic information about the patient and his tests saved in the data storage in the text
file. This file includes the following information about each test: first and last name of
the patient, patient number, address, date and time of the test. Such text file can be
useful to create the performed tests report for the given time period or the description
of the archive data storage content for CD-R. This file can be read by example by the
MS Excel program and edited in any way.

Format of the export file.

Line 1 – Name of the exported data storage

Line 2 – Full access path to the data storage
Line 3 - null
Line 4, 5, 6 ...etc. – consecutive tests saved in the following way:
Number /t name /t patient_number /t address /t test_date

/t – tabulator character separating the columns with data

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8. Security
The CardioTEST software was elaborated according to the requirements of the ISO
14971 and PN-EN 60601-1-4 standards that determine the safety requirements for
medical equipment and meets the requirements of the 93/42/EEC medical directive

Requirements for the users of the system

The user of the program is required to know the operation of MS Window operating
system, because the proper functioning of the program depends on the proper
functioning of the Windows operating system.

All errors in the MS Window environment and any faults connected with improper
usage of the program or destructive operation of the other programs will result on the
correct functioning of the CardioTEST program. Therefore, the other software should
not be run on this computer (with exception of the software installed by Aspel
company). The system should be also scanned against any viruses.

Minimum hardware requirements

– Computer compatible with IBM (according to norm: EN 60950).
– Operating system: Windows 7, Windows 8, Windows 10 (32 bit and 64 bit).
– Processor: PENTIUM 1600 MHz.
– 512 MB RAM.
– CD-ROM or DVD
– Hard drive min. 100 GB.
– Color monitor SVGA 17”.
– Laser print HP LaserJet .
Each device should bear CE mark.

Preferred printers – tested with Perfekt BIS program:

– HP LaserJet 1010 printer,
– HP LaserJet 1000 printer,
– OKIPAGE 14ex printer.

The described requirements are the minimum requirements. Any computer with the
above parameters has enough computing power for the correct cooperation with
training device and ECG transmission module, otherwise the system can work with
errors (e.g. outages in transmission, large delays in data transfer).

When working with CardioTEST program, the user should not run any additional
software. Each additional application operating in MS Windows system will decrease
the available computing power and can results in disturbances.

The computer instruction manual includes parameters connected with the live of
particular assemblies of the computer. These parameters are guaranteed by the

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manufacturer. When they will be exceeded, there is the possibility of errors and faults
in computer operation what will result in improper program operations.

System working conditions

During the system installation, the requirements of the EN 60601-1-1 should be

fulfilled regarding the medical devices, in particularly - computer with installed
CardioTEST program. must be located outside the patient area, in the distance
greater than 1.5 m and must operate in the conditions that will not negatively
influence the operation of the whole system. The detailed information are available in
the computer instruction and other equipment.

The user should take into consideration all eventual radiation sources and magnetic
fields that can interfere the operation of the system. The place in which the system is
located should be protected against vibrations, dust, corrosion factors, explosions,
against large and severe temperature changes, against humidity.

The stress system for the proper operations needs the proper temperature of the air.
Any exceeding of the temperature range can result in damages of the equipment,
therefore the computer and the screen should be placed in well ventilated rooms to
properly cool the system.
– Temperature: 0-40ºC.
– Humidity: <= 80%.
– Height: -500 m up to 4600 m.

Warnings

Earthing. To protect personnel operating the system, the computer and training
device are equipped with 3-core power cable that should be connected to the 3-core
socket with earthing. If, the installation site does not provide the socket with earthing,
then contact with the technical department.

Power. Because each power network can have temporarily outages in the energy
delivery, we recommend to use the emergency devices, such as UPS. This will
protect the whole system against damage and data loss.

Usage. Before starting the work with system, please perform the following activities:
– check, that the mechanical damages are not present,
– check, whether the system is properly connected,
– check, whether the printer is turned on,
– check the correctness of the acoustic system in the computer.

Attention! Do not start the work, if the equipment is damaged in any way. In such
case, contact with the technical department. All maintenance and service activities
must be performed by the qualified servicing personnel.

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Appendix A

Figure 63. Standard leads system

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Appendix B

Operating the Medical Diagnostics Workplace for ASPEL systems

Starting-up the system

1. Connect the power cable delivered by the manufacturer to the socket of the
power network equipped with the earthing pin.

2. Turn on the computer, monitor and printer using the buttons provided on the
enclosures of these devices.

3. Start the required application clicking with the mouse the proper icon placed
on the desktop.
Before starting, the device should be the subject of acclimatization for 24 hours.
The electric installation of the site in which the workplace is placed must provides
the PE earthing cable and conform IEC regulations regarding the electric
installation safety.

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