Sleep and Breathing

, Volume 23, Issue 1, pp 125–133 | Cite as

Sleep apnea detection: accuracy of using automated ECG analysis compared to manually scored polysomnography (apnea hypopnea index)

  • Hugi HilmissonEmail author
  • Neale Lange
  • Stephen P. Duntley
Sleep Breathing Physiology and Disorders • Original Article



Adequate sleep is fundamental to wellness and recovery from illnesses and lack thereof is associated with disease onset and progression resulting in adverse health outcomes. Measuring sleep quality and sleep apnea (SA) at the point of care utilizing data that is already collected is feasible and cost effective, using validated methods to unlock sleep information embedded in the data. The objective of this study is to determine the utility of automated analysis of a stored, robust signal widely collected in hospital and outpatient settings, a single lead electrocardiogram (ECG), using clinically validated algorithms, cardiopulmonary coupling (CPC), to objectively and accurately identify SA.


Retrospective analysis of de-identified PSG data with expert level scoring of Apnea Hypopnea Index (AHI) dividing the cohort into severe OSA (AHI > 30), moderate (AHI 15–30), mild (AHI 5–15), and no disease (AHI < 5) was compared with automated CPC analysis of a single lead ECG collected during sleep for each subject. Statistical analysis was used to compare the two methods.


Sixty-eight ECG recordings were analyzed. CPC identified patients with moderate to severe SA with sensitivity of 100%, specificity of 81%, and agreement of 93%, LR+ (positive likelihood ratio) 5.20, LR− (negative likelihood ratio) 0.00 and kappa 0.85 compared with manual scoring of AHI.


The automated CPC analysis of stored single lead ECG data often collected during sleep in the clinical setting can accurately identify sleep apnea, providing medically actionable information that can aid clinical decisions.


Sleep apnea Cardiopulmonary coupling Cyclic variation of heart rate Apnea Hypopnea Index 



American Academy of Sleep Medicine


Apnea Hypopnea Index


Cyclic alternating pattern


Cardiopulmonary coupling


Continuous positive airway pressure


Cardiovascular disease


Cyclic variation of heart rate


ECG-derived respiration






Elevated low-frequency broad-band


Elevated low-frequency narrow-band


Heart rate variability


High-frequency coupling


Low-frequency coupling


Non-rapid eye movement sleep


Non-cyclic alternating pattern


Prevalence adjusted and bias adjusted kappa


Rapid eye movement


Sleep Apnea Indicator


Sleep Quality Index


Very low frequency coupling



Dr. Thomas Penzel of Philipps-University, Marburg, Germany who provided the data for this analysis, PhysioBank Database November 2016).

Author’s contribution

Neale Lange: Drafting and final approval of the manuscript.

Hugi Hilmisson: Analysis of data, initial drafting, and final approval of the manuscript.

Stephen P Duntley: Final approval of the manuscript.

Compliance with ethical standards

Formal consent was not required for this analysis, as the data had already been de-identified.

Conflict of interest

Lange, Neale, MD:

Assistant Clinical Professor of Medicine, University of Colorado Health Sciences Center, Denver, CO; Partner Critical Care Pulmonary and Sleep Associates.

Dr. Lange declares no conflict of interest.

Hilmisson, Hugi, MA works as a data Analyst, MyCardio LLC. SleepImage is the brand name of MyCardio LLC, a privately held entity. MyCardio LLC is a licensee of the CPC algorithm, a method using ECG recordings during sleep to phenotype sleep and sleep apnea, from the Beth Israel Deaconess Medical Center, Boston, MA, USA.

Stephen P Duntley, MD declares no conflict of interest.


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Hugi Hilmisson
    • 1
    Email author
  • Neale Lange
    • 2
  • Stephen P. Duntley
    • 3
  1. 1.MyCardio-LLC, SleepImage®BroomfieldUSA
  2. 2.Division of Pulmonary Sciences and Critical Care MedicineUniversity of Colorado Health at Denver-Anschutz Medical CampusDenverUSA
  3. 3.Critical Care Pulmonary and Sleep AssociatesLakewoodUSA

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