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Accurate diagnosis of myocardial ischemia during activities of daily living, if possible, would provide immediate and substantial benefits to affected subjects, by reducing the time needed to determine and evaluate therapeutic interventions intended to reduce or eliminate transient ischemia. Although ST changes provide a sensitive indicator of ischemia, a variety of non-ischemic mechanisms can also result in ST changes, so that ECG-based diagnosis of ischemia is regarded as non-specific and unreliable. It may be possible, by study of the dynamics of ST changes, to improve the specificity of ECG criteria consistent with ischemia. The fourth annual PhysioNet/Computers in Cardiology Challenge encouraged participants to develop and evaluate methods for distinguishing ischemic and non-ischemic ST changes using a standard, meticulously annotated data set. The training data provided to participants, and the algorithms they developed, are available at http://-www.physionet.org/challenge/2003/.