Abstract Set

abstract-cufflessAN-set.
txt
1. IEEE Trans Biomed Eng. 2017 Apr;64(4):859-869. doi:
10.1109/TBME.2016.2580904.
Epub 2016 Jun 14.
Cuffless Blood Pressure Estimation Algorithms for Continuous Health-Care

Monitoring.
Kachuee M, Kiani MM, Mohammadzade H, Shabany M.
GOAL: Continuous blood pressure (BP) monitoring can provide invaluable

information about individuals' health conditions. However, BP is conventionally
measured using inconvenient cuff-based instruments, which prevents continuous BP
monitoring. This paper presents an efficient algorithm, based on the pulse

arrival time (PAT), for the continuous and cuffless estimation of the systolic
BP, diastolic blood pressure (DBP), and mean arterial pressure (MAP) values.
METHODS: The proposed framework estimates the BP values through processing vital
signals and extracting two types of features, which are based on either
physiological parameters or whole-based representation of vital signals.
Finally, the regression algorithms are employed for the BP estimation. Although
the proposed algorithm works reliably without any need for calibration, an
optional calibration procedure is also suggested, which can improve the system's
accuracy even further.

RESULTS: The proposed method is evaluated on about a thousand subjects using the
Association for the Advancement of Medical Instrumentation (AAMI) and the

British Hypertension Society (BHS) standards. The method complies with the AAMI
standard in the estimation of DBP and MAP values. Regarding the BHS protocol,
the results achieve grade A for the estimation of DBP and grade B for the
estimation of MAP.
CONCLUSION: We conclude that by using the PAT in combination with informative
features from the vital signals, the BP can be accurately and reliably estimated
in a noninvasive fashion.
SIGNIFICANCE: The results indicate that the proposed algorithm for the cuffless
estimation of the BP can potentially enable mobile health-care gadgets to
monitor the BP continuously.
DOI: 10.1109/TBME.2016.2580904
PMID: 27323356 [Indexed for MEDLINE]
2. Proc Natl Acad Sci U S A. 2018 Oct 30;115(44):11144-11149. doi:
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abstract-cufflessAN-set.txt
10.1073/pnas.1814392115. Epub 2018 Oct 15.
Relation between blood pressure and pulse wave velocity for human arteries.
Ma Y(1)(2), Choi J(3)(4)(5), Hourlier-Fargette A(3)(4)(5), Xue Y(3)(4)(6)(7),

Chung HU(4)(5), Lee JY(4)(5), Wang X(8), Xie Z(3)(4)(6)(7), Kang D(9), Wang
H(3)(4)(6)(7), Han S(9), Kang SK(10), Kang Y(11), Yu X(12), Slepian MJ(13), Raj
MS(4), Model JB(4), Feng X(1)(2), Ghaffari R(4)(5)(14), Rogers
JA(15)(4)(5)(7)(14)(16)(17)(18)(19)(20)(21)(22), Huang Y(15)(4)(6)(7).
Author information:
(1)Department of Engineering Mechanics, Tsinghua University, 100084 Beijing,
China.
(2)Center for Flexible Electronics Technology, Tsinghua University, 100084
Beijing, China.
(3)Department of Materials Science and Engineering, Northwestern University,
Evanston, IL 60208.
(4)Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL
60208.
(5)Simpson Querrey Institute for Bio-Nanotechnology, Northwestern University,
Evanston, IL 60208.
(6)Department of Civil and Environmental Engineering, Northwestern University,
Evanston, IL 60208.
(7)Department of Mechanical Engineering, Northwestern University, Evanston, IL
60208.
(8)School of Materials Science and Engineering, Xiangtan University, 411105
Hunan, China.
(9)Department of Mechanical Engineering, Ajou University, 16499 Suwon-si,
Republic of Korea.
(10)Department of Bio and Brain Engineering, Korea Advanced Institute of Science
and Technology, 34141 Daejeon, Republic of Korea.

(11)Department of Electrical and Computer Engineering, University of Illinois at
Urbana-Champaign, Urbana, IL 61801.

(12)Department of Biomedical Engineering, City University of Hong Kong, 999077
Hong Kong, China.
(13)Department of Medicine and Biomedical Engineering, Sarver Heart Center,
University of Arizona, Tucson, AZ 85724.
(14)Department of Chemistry and Biomedical Engineering, Northwestern University,
Evanston, IL 60208.
(15)Department of Materials Science and Engineering, Northwestern University,
Evanston, IL 60208; [email protected] [email protected].
(16)Department of Dermatology, Northwestern University, Evanston, IL 60208.
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(17)Feinberg School of Medicine Center for Bio-Integrated Electronics,
Northwestern University, Evanston, IL 60208.
(18)Department of Electrical Engineering and Computer Science, Northwestern
University, Evanston, IL 60208.
(19)Department of Neurological Surgery, Northwestern University, Evanston, IL
60208.
(20)Department of Chemistry, Northwestern University, Evanston, IL 60208.
(21)Department of Materials Science and Engineering, University of Illinois at
(22)Frederick Seitz Materials Research Laboratory, University of Illinois at
Comment in
Front Physiol. 2019 Sep 12;10:1179.
Continuous monitoring of blood pressure, an essential measure of health status,

typically requires complex, costly, and invasive techniques that can expose
patients to risks of complications. Continuous, cuffless, and noninvasive blood
pressure monitoring methods that correlate measured pulse wave velocity (PWV) to
the blood pressure via the Moens-Korteweg (MK) and Hughes Equations, offer
promising alternatives. The MK Equation, however, involves two assumptions that
do not hold for human arteries, and the Hughes Equation is empirical, without
any theoretical basis. The results presented here establish a relation between
the blood pressure P and PWV that does not rely on the Hughes Equation nor on
the assumptions used in the MK Equation. This relation degenerates to the MK
Equation under extremely low blood pressures, and it accurately captures the
results of in vitro experiments using artificial blood vessels at comparatively
high pressures. For human arteries, which are well characterized by the Fung
hyperelastic model, a simple formula between P and PWV is established within the
range of human blood pressures. This formula is validated by literature data as

well as by experiments on human subjects, with applicability in the
determination of blood pressure from PWV in continuous, cuffless, and
noninvasive blood pressure monitoring systems.
DOI: 10.1073/pnas.1814392115
PMCID: PMC6217416
Conflict of interest statement: The authors declare no conflict of interest.
3. Stud Health Technol Inform. 2018;249:77-83.
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Cuffless Blood Pressure Estimation Using Pulse Transit Time and
Photoplethysmogram Intensity Ratio.
Gholamhosseini H(1), Baig M(1), Rastegar S(1), Lindén M(2).
Author information:
(1)School of Engineering, Computer and Mathematical Sciences, Auckland
University of Technology, Auckland, New Zealand.
(2)School of Innovation, Design, and Engineering, Mälardalen University,
Västerås, Sweden.
High blood pressure (BP) is one of the common risk factors for heart disease,
stroke, congestive heart failure, and kidney disease. An accurate, continuous
and cuffless BP monitoring technique could help clinicians improve the rate of
prevention, detection, and treatment of hypertension and related diseases. Pulse
transit time (PTT) has attracted interest as an index of BP changes for cuffless
BP measurement techniques. Currently, PPT-based BP measurement approaches have

improved and are able to relieve the discomfort associated with an inflated cuff
such as that used in auscultatory and oscillometric BP measurement techniques.

However, PTT can only track the BP variation in high frequency (HF) which limits
the true representation of BP changes. This paper presents a continuous and

cuffless BP monitoring method based on multi-parameter fusion. We used
photoplethysmogram (PPG) and a two-lead electrocardiogram (ECG) and employed an
algorithm based on PTT and the PPG intensity ratio (PIR) to continuously track
BP in both high and low frequencies and estimate systolic and diastolic BP.
4. Annu Int Conf IEEE Eng Med Biol Soc. 2020 Jul;2020:4269-4272. doi:
10.1109/EMBC44109.2020.9175699.
Cuffless and Continuous Blood Pressure Estimation From PPG Signals Using
Recurrent Neural Networks.
El Hajj C, Kyriacou PA.
This paper proposes cuffless and continuous blood pressure estimation utilising
Photoplethysmography (PPG) signals and state of the art recurrent network
models, namely, Long Short Term Memory and Gated Recurrent Units. The models
were validated on wide range of varying blood pressure and PPG signals acquired
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from the Multiparameter Intelligent Monitoring in Intensive Care database. Many
features were extracted from the PPG waveform and several machine learning
techniques were employed in an attempt to eliminate collinearity and reduce the
size of input feature vector. Consequently, the most effective features for
blood pressure estimation were selected. Experimental results show that the
accuracy of the proposed methods outperform traditional models applied in the
literature. The results satisfy the American National Standards of the
Association for the Advancement of Medical Instrumentation.
DOI: 10.1109/EMBC44109.2020.9175699
5. IEEE Trans Biomed Eng. 2019 Apr;66(4):967-976. doi:

10.1109/TBME.2018.2865751.
Epub 2018 Aug 17.
Noninvasive Cuffless Blood Pressure Estimation Using Pulse Transit Time and
Impedance Plethysmography.
Huynh TH, Jafari R, Chung WY.
OBJECTIVE: To demonstrate the feasibility of everaging impedance plethysmography
(IPG) for detection of pulse transit time (PTT) and estimation of blood pressure
(BP).
METHODS: We first established the relationship between BP, PTT, and arterial
impedance (i.e., the IPG observations). The IPG sensor was placed on the wrist
while the photoplethysmography sensor was attached to the index finger to
measure the PTT. With a cuff-based BP monitoring system placed on the upper arm
as a reference, our proposed methodology was evaluated on 15 young, healthy
human subjects leveraging handgrip exercises to manipulate BP/PTT and compared
to several conventional PTT models to assess the efficacy of PTT/BP detections.
RESULTS: The proposed model correlated with BP fairly well with group average
correlation coefficients of [Formula: see text] for systolic BP (SBP) and
[Formula: see text] for diastolic BP (DBP). In comparison with the other PTT
methods, PTT-IPG-based BP estimation provided a lower root-mean-squared-error of
[Formula: see text] and [Formula: see text] for SBP and DBP, respectively.
CONCLUSION: We conclude that the measurement of arterial impedance via IPG
methods is an adequate indicator to estimate BP. The proposed method appears to
offer superiority compared to the conventional PTT estimation approaches.
SIGNIFICANCE: Using impedance magnitude to estimate PTT offers promise to
realize wearable and cuffless BP devices.
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DOI: 10.1109/TBME.2018.2865751
6. Physiol Meas. 2019 Jul 23;40(7):075001. doi: 10.1088/1361-6579/ab1f17.
Noninvasive cuffless blood pressure estimation using pulse transit time,

Womersley number, and photoplethysmogram intensity ratio.
Thambiraj G(1), Gandhi U, Devanand V, Mangalanathan U.
Author information:
(1)Instrumentation and Control Engineering, National Institute of Technology,
Tiruchirappalli, India.
OBJECTIVE: Continuous cuffless blood pressure (BP) monitoring research has

emerged as blood pressure is one of the dynamic parameters which reflects
cardiac arrhythmias and rheological disorders without the drawbacks of current
techniques. All the existing measurement techniques are cuff-based with
drawbacks such as being discontinuous in nature, being uncomfortable for the
patient, etc. Therefore, the goal is to develop an algorithm to estimate BP
accurately using the pulse transit time (PTT), photoplethysmogram intensity
ratio (PIR) and Womersley number (α) in a noninvasive way.
APPROACH: The PTT technique holds the promise of real-time, cuffless, continuous
BP monitoring in clinical settings. However, the non-Newtonian fluid nature of

blood is considered insignificant in the conventional PTT model-based BP
modeling. In the proposed work, α, representing viscous effects, along with PTT
and PIR, is included in the algorithm since it is also one of the parameters
that affects the BP.
MAIN RESULTS: The proposed algorithm is evaluated with 42 healthy and 39
diseased subjects and compared with the other conventional techniques to
evaluate the importance of viscous effects in BP, using performance metrics like
mean ± standard deviation, and 95% confidence interval for bias and limits of
agreement; a better estimate is achieved with the proposed algorithm.
SIGNIFICANCE: The proposed algorithm reflects the influences of vasomotor tone
and baroflex as well, which makes it suitable for the assessment of BP in both
healthy and diseased subjects, with improved accuracy than the current
measurement techniques.
DOI: 10.1088/1361-6579/ab1f17
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10.1109/EMBC.2019.8856706.
Cuffless Blood Pressure Estimation from only the Waveform of

Photoplethysmography using CNN.
Shimazaki S, Kawanaka H, Ishikawa H, Inoue K, Oguri K.
Although the pulse transit time is generally used for blood pressure estimation
without a cuff, a method of estimating blood pressure only from
photoplethysmography (PPG) based on the relationship between pulse waveform and
blood pressure has been studied. This can eliminate the need for an
electrocardiogram and allow more continuous and simpler blood pressure
measurement. Previous studies have proposed methods of machine learning by
extracting features such as wave height and time difference, or generating
features with an auto-encoder. In this paper, we propose a method to estimate
blood pressure and to automatically generate features from pulse wave using the
convolutional neural networks (CNN). By comparing the accuracy of the proposed
method with that of the conventional method, the effectiveness of cuffless blood
pressure estimation from only PPG by using CNN is examined.
DOI: 10.1109/EMBC.2019.8856706
8. Sci Rep. 2018 May 8;8(1):7298. doi: 10.1038/s41598-018-25681-5.
Cuffless blood pressure estimation using only a smartphone.
Matsumura K(1)(2)(3), Rolfe P(4)(5), Toda S(6), Yamakoshi T(7).
Author information:
(1)Division of Bioengineering and Bioinformatics, Graduate School of Information
Science and Technology, Hokkaido University, Hokkaido, Japan.

[email protected].
(2)Computer Science Laboratory, Comprehensive Research Organization, Fukuoka
Institute of Technology, Fukuoka, Japan. [email protected].
(3)Faculty of Medicine, University of Toyama, Toyama, Japan.
[email protected].
(4)Department of Automatic Measurement and Control, Harbin Institute of
Technology, Harbin, China.
(5)Oxford BioHorizons Ltd., Maidstone, United Kingdom.
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(6)Division of Bioengineering and Bioinformatics, Graduate School of Information
Science and Technology, Hokkaido University, Hokkaido, Japan.

(7)Information and Systems Engineering, Graduate School of Engineering, Fukuoka
Institute of Technology, Fukuoka, Japan.
Cuffless blood pressure (BP) measurement is an all-inclusive term for a method

that aims to measure BP without using a cuff. Recent cuffless technology has
made it possible to estimate BP with reasonable accuracy. However, mainstream
methods require an electrocardiogram and photoplethysmogram measurements, and
frequent calibration procedures using a cuff sphygmomanometer. We therefore
developed a far simpler cuffless method, using only heart rate (HR) and modified
normalized pulse volume (mNPV) that can be measured using a smartphone, based on
the knowledge that ln BP = ln cardiac output (CO) + ln total peripheral

resistance (TPR), where CO and TPR are correlated with HR and mNPV,
respectively. Here, we show that mean arterial pressure (MAP), systolic BP
(SBP), and diastolic BP (DBP) could be estimated using the exponential
transformation of linear polynomial equation, (a × ln HR) + (b × ln
mNPV) + constant, using only a smartphone, with an accuracy of R > 0.70. This
implies that our cuffless method could convert a large number of smartphones or
smart watches into simplified sphygmomanometers.
DOI: 10.1038/s41598-018-25681-5
PMCID: PMC5940836
Conflict of interest statement: We have the following interests. The

iPhysioMeterSM app, distributed for free in the iTunes App Store (Apple, Inc.)
and used in this study, was developed by two of the authors of the present paper
(K.M. and T.Y.). One of the co-authors (P.R.) currently serves as Director of
Science and Technology of Oxford BioHorizons Ltd., a consultancy company, and as
a grant review committee member of the European Commission. There are no further
patents, products in development or marketed products to declare.
9. Physiol Meas. 2018 Feb 26;39(2):025005. doi: 10.1088/1361-6579/aaa454.
New photoplethysmogram indicators for improving cuffless and continuous blood

pressure estimation accuracy.
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Lin WH(1), Wang H, Samuel OW, Liu G, Huang Z, Li G.
Author information:
(1)CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen
Institutes of Advanced Technology (SIAT), Chinese Academy of Sciences (CAS),
Shenzhen 518055, People's Republic of China. Research Center for Neural
Engineering at SIAT, CAS, Shenzhen 518055, People's Republic of China. Shenzhen
College of Advanced Technology, UCAS, Shenzhen 518055, People's Republic of
China.
Comment in
Physiol Meas. 2018 Sep 27;39(9):098001.
Physiol Meas. 2018 Sep 27;39(9):098002.
OBJECTIVE: The accuracy of cuffless and continuous blood pressure (BP)

estimation has been improved, but it is still unsatisfactory for clinical uses.
This study was designed to further increase BP estimation accuracy.
APPROACH: In this study, a number of new indicators were extracted from
photoplethysmogram (PPG) recordings and a linear regression method was used to
construct BP estimation models based on the PPG indicators and pulse transit
time (PTT). The performance of the BP estimation models was evaluated by the PPG
recordings from 22 subjects when they performed mental arithmetic stress and
Valsalva's manoeuvre tasks that could induce BP fluctuations.
MAIN RESULTS: Our results showed that the best PPG-based BP estimation model
could achieve a decrease of 0.31 ± 0.08 mmHg in systolic BP (SBP) and
0.33 ± 0.01 mmHg in diastolic BP (DBP) on estimation errors of grand absolute
mean (GAM) and standard deviation (GSD) in comparison to the previously reported
PPG-based methods. The best estimation model based on the combination of PPG and
PPT could achieve a decrease (GAM & GSD) of 0.81 ± 0.95 mmHg in SBP and
0.75 ± 0.54 mmHg in DBP in comparison to the PPT-based methods.
SIGNIFICANCE: The findings suggest that the newly proposed PPG indicators would
be promising for improving the accuracy of continuous and cuffless BP
estimation.
DOI: 10.1088/1361-6579/aaa454
10. Sensors (Basel). 2020 Sep 30;20(19):5606. doi: 10.3390/s20195606.
Real-Time Cuffless Continuous Blood Pressure Estimation Using Deep Learning

Model.
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Li YH(1), Harfiya LN(1), Purwandari K(1), Lin YD(2).
Author information:
(1)Department of Computer Science and Information Engineering, National Central
University, Taoyuan 32001, Taiwan.
(2)Department of Automatic Control Engineering, Feng Chia University, Taichung
40724, Taiwan.
Blood pressure monitoring is one avenue to monitor people's health conditions.

Early detection of abnormal blood pressure can help patients to get early
treatment and reduce mortality associated with cardiovascular diseases.
Therefore, it is very valuable to have a mechanism to perform real-time
monitoring for blood pressure changes in patients. In this paper, we propose
deep learning regression models using an electrocardiogram (ECG) and
photoplethysmogram (PPG) for the real-time estimation of systolic blood pressure
(SBP) and diastolic blood pressure (DBP) values. We use a bidirectional layer of
long short-term memory (LSTM) as the first layer and add a residual connection
inside each of the following layers of the LSTMs. We also perform experiments to
compare the performance between the traditional machine learning methods,

another existing deep learning model, and the proposed deep learning models
using the dataset of Physionet's multiparameter intelligent monitoring in
intensive care II (MIMIC II) as the source of ECG and PPG signals as well as the
arterial blood pressure (ABP) signal. The results show that the proposed model
outperforms the existing methods and is able to achieve accurate estimation
which is promising in order to be applied in clinical practice effectively.
DOI: 10.3390/s20195606
PMCID: PMC7584036
11. Hosp Pract (1995). 2019 Oct;47(4):211-215. doi:

10.1080/21548331.2019.1656991.
Epub 2019 Aug 26.
The accuracy of blood pressure measurement by a smartwatch and a portable health
device.
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van Helmond N(1)(2), Freeman CG(3), Hahnen C(1)(4), Haldar N(3), Hamati JN(3),
Bard DM(3), Murali V(3), Merli GJ(5), Joseph JI(1).
Author information:
(1)Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson
University, Philadelphia, PA, USA.

(2)Department of Anesthesiology, Cooper Medical School of Rowan University,
Cooper University Hospital, Camden, NJ, USA.
(3)Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA,
USA.
(4)College of Biomedical Sciences, Radboud University, Nijmegen, the
Netherlands.
(5)Department of Surgery and Medicine, Sidney Kimmel Medical College, Thomas
Jefferson University, Philadelphia, PA, USA.
Objectives: Handheld medical devices and smartwatches that measure BP without a

cuff have recently become available. Since these measurements are relatively
more user-friendly than conventional cuff-based measurements they may aid in
more frequent BP monitoring. We investigated the accuracy and precision of two
popular cuff-less devices: the Everlast smartwatch and the BodiMetrics
Performance Monitor.Methods: We enrolled 127 patients from the Thomas Jefferson
University Hospital Preadmission Testing Center. Research staff were trained to
measure BP according to manufacturer guidelines for the investigational devices.
The Everlast smartwatch provides measurements of systolic (SBP) and diastolic

(DBP) BP, whereas the Bodimetrics only provides SBP. Reference BP measurements
were obtained using a hospital-grade automated sphygmomanometer. After 5 minutes
of quiet sitting, four standard and three investigational BP measurements were

taken with sixty seconds in between each measurement. The reference BP value was
calculated by determining the average of the 2 standard BP measurements that

bounded the investigational measurements. We thus determined 3 comparison pairs
for each investigational device in each subject. We calculated the mean (SD) of
the absolute difference between the respective investigational devices and the
reference for SBP and DBP.Results: Data from 42 individuals was excluded because
of variation in standard BP measurements per prespecified rules. Of 85

participants used for analysis, 36 (42%) were women, the mean (SD) age was 53
(21) years, 32 (38%) self-reported hypertension, and 97% of these (n = 31)
reported taking antihypertensive medications. The average differences between
the Everlast watch and reference were 16.9 (13.5) mm Hg for SBP and 8.3 (6.1) mm
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Hg for DBP. The average difference between the Bodimetrics performance monitor
and the reference was 5.3 (4.7) mm Hg for SBP.Conclusions: The Everlast
smartwatch and the BodiMetrics Performance Monitor we tested are not accurate
enough to be used as BP measurement devices.
DOI: 10.1080/21548331.2019.1656991
10.1109/EMBC.2019.8856749.
The Cuffless Blood Pressure Measurement with Multi-dimension Regression Model

based on Characteristics of Pulse Waveform.
Liu SH, Lai SH, Wang JJ, Tan TH, Huang YF.
According to the advancement of wearable technology, many physiological

monitoring instruments are gradually converted into wearable devices. But, the
blood pressure monitor still is a cuff-type device in the consumer market, which
also does not do the beat-by-beat continuous blood pressure measurement. Now,
the cuffless blood pressure measurement has been developed based on the pulse
transit time (PTT) but its accuracy is not better. According to the cardiac
hemodynamic theorem, the blood pressure relates with the arterial
characteristics. Therefore, the purpose of this study was to use the
characteristics of the pulse wave measured by photoplethysmography (PPG) to
estimate the blood pressure with a multi-dimension regression model. The contour
of pulse wave includes some characteristics of the artery. There were 10

subjects participating the experiment, and the blood pressure of the subject was
changed by the exercise. The results showed that the cumulate root mean square
error of the estimated systolic and diastolic pressures with the
multi-parameters were 69.3 mmHg and 39.8 mmHg were better than only using one
parameter, PTT, 82.1 mmHg and 45.2 mmHg, respectively.
DOI: 10.1109/EMBC.2019.8856749
13. Biosens Bioelectron. 2020 Nov 1;167:112483. doi: 10.1016/j.bios.2020.112483.
Epub 2020 Jul 29.
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An instrument for measuring blood pressure and assessing cardiovascular health

from the fingertip.
Panula T(1), Koivisto T(2), Pänkäälä M(2), Niiranen T(3), Kantola I(4), Kaisti
M(5).
Author information:
(1)Department of Future Technologies, University of Turku, 20520, Turku,
Finland. Electronic address: [email protected].
Finland.
(3)Department of Clinical Medicine, University of Turku, 20520, Turku, Finland.
(4)Turku University Hospital, 20521, Turku, Finland.
Finland; Department of Bioengineering, Imperial College London, London SW7 2AZ,
UK. Electronic address: [email protected].
Despite blood pressure being one the leading modifiable risk factors for
cardiovascular disease and death, it is severely under-monitored. For this
challenge we propose a finger artery non-invasive tono-oscillometric monitor
(FANTOM) which is an automated low-cost instrument for measuring blood pressure
and hemodynamic parameters from the fingertip. The sensing technology is highly
scalable and could be integrated to a pulse oximeter probe for increased patient
comfort. A tonometric cuff-less mechatronic system is used to apply pressure on

the fingertip for (i) measuring oscillometric blood pressure, (ii) recording
arterial waveform and for (iii) constructing central blood pressure (CBP)
waveform. Clinical study on volunteers (n = 33) was performed against a
commercially available arm cuff device yielding systolic and diastolic readings
((mean±SD) mmHg) of (-0.9 ± 7.3) mmHg and (-3.3 ± 6.6) mmHg respectively. The
results comply with the Association for the Advancement of Medical
Instrumentation (AAMI) standard for non-invasive blood pressure monitors. The
arterial pulse recording morphology was compared against a volume clamp device
(CNSystems CNAP 500) (n = 3) resulting in similar performance. Comparison of CBP
against a pulse wave analysis (PWA) device (Atcor Medical Sphygmocor XCEL)
(n = 5) revealed central aortic systolic pulse (CASP) and central augmentation
index (cAIx) estimates with precision and accuracy of (2.0 ± 3.7) mmHg and
(1.4 ± 6.2)% respectively. In conclusion, the results indicate that the proposed
technology could be useful in the development of new portable or wearable blood

pressure monitors. The sensing technology is highly scalable and could be
integrated to a pulse oximeter probe for increased patient comfort.
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Copyright © 2020 Elsevier B.V. All rights reserved.
DOI: 10.1016/j.bios.2020.112483
14. Physiol Meas. 2018 Sep 27;39(9):098002. doi: 10.1088/1361-6579/aadf17.
Reply to Comment on 'New photoplethysmogram indicators for improving cuffless

and continuous blood pressure estimation accuracy'.
Lin WH(1), Samuel OW, Li G.
Author information:
(1)CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen
Institutes of Advanced Technology (SIAT), Chinese Academy of Sciences (CAS),
Shenzhen 518055, People's Republic of China. Research Center for Neural
Engineering at SIAT, CAS, Shenzhen 518055, People's Republic of China. Shenzhen
College of Advanced Technology, University of Chinese Academy of Sciences
(UCAS), Shenzhen 518055, People's Republic of China.
Comment on
Physiol Meas. 2018 Feb 26;39(2):025005.
Physiol Meas. 2018 Sep 27;39(9):098001.
OBJECTIVE: This article was written by the invitation of the editorial board of
Physiological Measurement. It is a Reply to the Comment regarding our recently
published paper entitled 'New photoplethysmogram indicators for improving
cuffless and continuous blood pressure estimation accuracy' (Lin et al 2018
Physiol. Meas. 29 025005).
APPROACH: We appreciate van Helmond and Joseph's (2018 Physiol. Meas. 098001)
interests and comments on our previous paper. In the Comment, they discussed in
detail the physiology underlying the pulse arrive time (PAT)-based methods for
blood pressure (BP) measurement, and concluded that there are inherent
physiological reasons precluding the development of an accurate continuous
cuffless BP measurement using PAT-based methods. We could agree with the
comments of van Helmond and Joseph about the physiology underlying PAT-based
methods for BP measurement. It may be difficult to minimize the confounding
effects of physiological factors such as pre-ejection period and smooth muscle
tone, etc. However, in this Reply, we discuss some potential solutions to deal
with these problems from an engineering point of view.
MAIN RESULTS: When heart rate, more photoplethysmogram (PPG) features, PAT,
robust machine learning models, and other techniques were adopted for BP
estimation, it is promising for improving the accuracy of BP estimation to an
acceptable range that can meet professional standards (e.g. Advancement of
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Medical Instrumentation (AAMI) standard, British Hypertension Society (BHS)
protocol).
SIGNIFICANCE: PAT- and/or PPG-based methods may be a promising technique for
continuous and unobtrusive blood pressure measurement.
DOI: 10.1088/1361-6579/aadf17
15. Healthc Technol Lett. 2020 Jun 23;7(4):98-102. doi: 10.1049/htl.2019.0105.

eCollection 2020 Aug.
Blood pressure estimation system using human body communication-based

electrocardiograph and photoplethysmography.
Sawatari Y(1), Wang J(1), Anzai D(1).
Author information:
(1)Nagoya Institute of Technology, Nagoya 466-8555, Japan.
In order to realise low-load cuffless and continuous blood pressure measurement

in daily life, the authors developed a blood pressure estimation system
combining human body communication-based wearable electrocardiograph and
reflectance photoplethysmography. The principle is based on a relationship
between the pulse arrive time and the systolic blood pressure. The pulse arrive
time is the time period between the R-wave in electrocardiograph and peak of
pulse wave. The greatest feature is the use of a human body communication-based
electrocardiograph which can provide automatic synchronisation in time between
the measured electrocardiograph and pulse wave signals to obtain the pulse
arrive time so that no additional synchronisation circuit is required. Using
this system, the authors measured the pulse arrive time from the
electrocardiograph and pulse wave signals in real time, estimated the systolic
blood pressure and compared the result with that measured by a cuff
sphygmomanometer. The authors found that the root mean square error of the
estimated blood pressure and the actual value measured using the cuff
sphygmomanometer was 4.5 mmHg or less, and the correlation coefficient was >0.6
with a P value much <0.05. These results show the validity of the developed
system for cuffless and continuous blood pressure estimation.
DOI: 10.1049/htl.2019.0105
PMCID: PMC7494369
PMID: 32983546
16. Physiol Meas. 2018 Sep 5;39(9):095002. doi: 10.1088/1361-6579/aad902.
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Cuffless blood-pressure estimation method using a heart-rate variability-derived
parameter.
Chen Y(1), Shi S, Liu YK, Huang SL, Ma T.
Author information:
(1)Department of Electronic and Information Engineering, Harbin Institute of
Technology Shenzhen Graduate School, Shenzhen, People's Republic of China.
Authors contributed equally to this work.
OBJECTIVE: Cuffless blood-pressure (BP) estimation has attracted widespread

interest owing to its potential for long-term, non-invasive BP monitoring. But
it is still impractical in clinical settings, mainly owing to ongoing challenges
with respect to accuracy in hypertensive patients. To better estimate the BP,

the current study proposes a new cuffless estimation method that includes a
sympathetic tone, which has been reported with a varied pattern in hypertensive
patients.
APPROACH: First, the heart-rate variability of all subjects is investigated, and
a new parameter, the heart-rate power spectrum ratio (HPSR), is proposed to

indicate BP dynamics under sympathetic regulation. Then, a new BP estimation
model is constructed by integrating HPSP with the pulse transit time (PTT) and
photoplethysmography intensity ratio. The estimation accuracy is further
evaluated by making comparisons with the standard sphygmomanometer BP on 60
subjects (29 hypertensive and 31 normotensive).
MAIN RESULTS: A significant increase in HPSR was observed in hypertensive
patients compared to normotensive subjects. Of the 60 subjects, the estimation
accuracy was 0.73 ± 10.04 mmHg for systolic BP (SBP) and 0.90 ± 7.10 mmHg
for diastolic BP (DBP) in hypertensive patients, which is comparable to
0.54 ± 7.52 mmHg for SBP and 0.82 ± 6.20 mmHg for DBP in normotensive
subjects. Furthermore, the proposed method overperformed the traditional
PTT-based algorithm by reducing the 3 mmHg error in the standard deviation in
hypertensive patients.
SIGNIFICANCE: The results of the current study demonstrate that the inclusion of
factors associated with autonomic activities in the BP estimation model would

improve the BP estimation accuracy, especially for hypertensive subjects.
DOI: 10.1088/1361-6579/aad902
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10.1109/EMBC.2019.8857864.
Cuff-Less Blood Pressure Monitoring with a 3-Axis Accelerometer.
Chang E, Wang S, Cheng CK, Gupta A, Hsu PH, Hsu PY, Liu HL, Moffitt A, Ren A,
Tsaur I.
OBJECTIVE: The aim was to propose a cuff-less, cost-efficient, and

ultra-convenient blood pressure monitoring technique with a 3-axis
accelerometer.
METHODS: The efficacy of the proposed approach was examined in 8 young healthy
volunteers undergoing different activities with a 3-axis accelerometer leveled
on their upper chest. The 3-dimensional accelerations were exploited to select
features for the calculation of systolic pressure (SP) and diastolic pressure
(DP); the whole process involved signal processing, feature extraction, linear
multivariate regression, and leave-one-out cross validations (LOOCV).
RESULTS: DP and SP could be approximated with the linear combination of the
extracted features: the L2 norm of lateral acceleration for both DP and SP,
state variation (defined in the proposed algorithm) of vertical acceleration for
SP, and I-J interval (defined in ballistocardiogram) of vertical acceleration

for DP. The correlation coefficient (r) of the estimated and the measured DP was
0.97, and for SP, r = 0.96. In LOOCV, our best validated results in difference
errors were -0.02±3.82 mmHg for DP and -0.59 ± 7.46 mmHg for SP.
CONCLUSION: Compared to AAMI criteria, the proposed acceleration-based technique
fulfilled the requirement. The accelerometer-based technique showed the

potential to monitor blood pressure cuff-lessly, cost-efficiently,
ultra-conveniently, and to be embedded in a long-term wearable device for
clinical usage.
DOI: 10.1109/EMBC.2019.8857864
18. IEEE Trans Biomed Circuits Syst. 2019 Dec;13(6):1723-1735. doi:

10.1109/TBCAS.2019.2946661. Epub 2019 Oct 10.
Cuffless Blood Pressure Monitoring from an Array of Wrist Bio-Impedance Sensors

Using Subject-Specific Regression Models: Proof of Concept.
Ibrahim B, Jafari R.
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Continuous and beat-to-beat monitoring of blood pressure (BP), compared to
office-based BP measurement, provides significant advantages in predicting
future cardiovascular disease. Traditional BP measurement methods are based on a
cuff, which is bulky, obtrusive and not applicable to continuous monitoring.

Measurement of pulse transit time (PTT) is one of the prominent cuffless methods
for continuous BP monitoring. PTT is the time taken by the pressure pulse to
travel between two points in an arterial vessel, which is correlated with the
BP. In this paper, we present a new cuffless BP method using an array of
wrist-worn bio-impedance sensors placed on the radial and the ulnar arteries of
the wrist to monitor the arterial pressure pulse from the blood volume changes
at each sensor site. BP is accurately estimated by using AdaBoost regression
model based on selected arterial pressure pulse features such as transit time,
amplitude and slope of the pressure pulse, which are dependent on the cardiac
activity and the vascular properties of the wrist arteries. A separate model is
developed for each subject based on calibration data to capture the individual
variations of BP parameters. In this pilot study, data was collected from 10
healthy participants with age ranges from 18 to 30 years after exercising using
our custom low-noise bio-impedance sensing hardware. Post-exercise BP was
accurately estimated with an average correlation coefficient and root mean
square error (RMSE) of 0.77 and 2.6 mmHg for the diastolic BP and 0.86 and 3.4
mmHg for the systolic BP.
DOI: 10.1109/TBCAS.2019.2946661
PMCID: PMC7028300
10.1109/EMBC.2019.8856332.
Continuous Tracking of Changes in Systolic Blood Pressure using BCG and ECG.
He S, Dajani HR, Meade RD, Kenny GP, Bolic M.
Blood pressure (BP) is an important physiological marker of human health. It is

commonly measured by a cuff-based monitor via either auscultatory or
oscillometric methods. Recently, significant research has been conducted to
mathematically estimate BP from pulse transit time (PTT) to enable cuffless and
continuous BP measurement. In this research, a new time reference, RJ interval,
which is the time delay between electrocardiogram (ECG) R peak and
ballistocardiogram (BCG) J peak was evaluated to determine if it can be used as
a surrogate of PTT in cuffless BP estimation. Biomedical signals from ten
healthy subjects were acquired by BCG, ECG and PPG sensors and the continuous
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reference BP data were collected by a cuff-based Finometer PRO BP monitor. An
exponential model was employed to estimate systolic blood pressure (SBP) using
RJ interval and PTT. RJ intervals extracted from ECG and BCG were shown to be
useful in evaluating trends of SBP and can be the surrogate of PTT in cuffless
SBP estimation.
DOI: 10.1109/EMBC.2019.8856332
20. Curr Hypertens Rep. 2016 Jun;18(6):49. doi: 10.1007/s11906-016-0650-9.
New Approaches to Evaluating and Monitoring Blood Pressure.
Goldberg EM(1), Levy PD(2).
Author information:
(1)Department of Emergency Medicine & Center of Gerontology and Healthcare
Research, Brown University, 55 Claverick Street, Providence, RI, 02903, USA.
[email protected].
(2)Department of Emergency Medicine and Cardiovascular Research Institute, Wayne
State University School of Medicine, Integrated Biosciences Center, 6135

Woodward Ave, Detroit, MI, 48202, USA.
Digital health innovations for hypertension include cuffless blood pressure

sensors, wireless smartphone-enabled upper arm blood pressure monitors, mobile
applications, and remote monitoring technologies. Wearable trackers have drawn
interest from medical professionals and patients alike. They have the potential
to improve hypertension control and medication adherence through easier logging
of repeated blood pressure measurements, better connectivity with health-care
providers, and medication reminder alerts. With increasing emphasis on home and
ambulatory blood pressure monitoring to confirm hypertension prior to treatment,
such devices also can help improve the diagnostic landscape. However, privacy,
accuracy, and cost concerns have prevented widespread clinical uptake. To foster
implementation, device designers and clinical researchers should collaborate on

development of rigorous clinical trials that test cardiovascular outcomes
associated with emerging technologies. We review the current literature on
mobile health technologies and novel diagnostic and management protocols and
make recommendations on how to incorporate these innovations into practice.
DOI: 10.1007/s11906-016-0650-9
PMCID: PMC8049529
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Conflict of interest statement: Conflict of Interest Dr. Goldberg declares no

conflict of interest. Dr. Levy declares personal fees and non-financial support
from The Medicine Company and Chiesi USA.
10.1109/EMBC.2019.8857709.
Cuff-less Blood Pressure Measurement Using Supplementary ECG and PPG Features
Extracted Through Wavelet Transformation.
Singla M, Sistla P, Azeemuddin S.
Cuff-less blood pressure (BP) is essential for continuous health monitoring to

prevent diseases such as hypertension. Due to the discomfort caused by inflation
and deflation of the cuff, it is not possible to monitor continuously. Although

pulse transit time (PTT) based approach is commonly used, other parameters also
vary with BP. Multi-parameter models are developed using regression analysis, to
estimate systolic blood pressure (SBP) and diastolic blood pressure (DBP).
Hence, the correlation of multiple extracted features with the blood pressure is
proved. To achieve this, simultaneous electrocardiogram (ECG) and

photoplethysmographic (PPG) along with respective BP data were collected. The
developed algorithm uses wavelet transformation on ECG and PPG signals for
detection of the occurrence of essential wave points precisely, even in the
presence of artifacts. Pulse wave analysis (PWA) is performed to create a
feature vector. From the experimental results, it is found that, the SBP model
gives mean error of 0.4916 mmHg, with standard deviation of 6.3986 mmHg, whereas
for DBP model, mean error is 0.2527 mmHg and standard deviation is 3.2835 mmHg
which is acceptable as per the British Hypertension Society (BHS) and
Association for the Advancement of Medical Instruments (AAMI) standards. After
the removal of BP oddities, mean absolute error improves from 5.625 to 3.854
mmHg for SBP and from 2.564 to 2.144 mmHg for DBP.
DOI: 10.1109/EMBC.2019.8857709
22. Sensors (Basel). 2018 Aug 23;18(9):2772. doi: 10.3390/s18092772.
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Recent Research and Developing Trends of Wearable Sensors for Detecting Blood
Pressure.
Arakawa T(1).
Author information:
(1)Department of Mechanical Systems Engineering, Aichi University of Technology,
Gamagori, Aichi 443-0047, Japan. [email protected].
Blood pressure is considered an index to measure a person's health or state. The
IEEE published a standard for wearable cuffless blood pressure measuring

devices, which was certified as IEEE1708 on 26 August 2014, and, according to
this standard, the development of wearable devices based on blood pressure is
expected in the future. Considering this, blood pressure should be detectable
all the time and everywhere, and this can help improve health consciousness. In
this review, we introduce the recent development of wearable blood pressure
measuring devices and research trends, and present the future prospects for
blood pressure measuring devices.
DOI: 10.3390/s18092772
PMCID: PMC6165193
Conflict of interest statement: The author declares no conflict of interest.
23. Front Physiol. 2020 Sep 9;11:575407. doi: 10.3389/fphys.2020.575407.

eCollection
2020.
Continuous Blood Pressure Estimation From Electrocardiogram and

Photoplethysmogram During Arrhythmias.
Liu Z(1)(2), Zhou B(3), Li Y(1)(2), Tang M(3), Miao F(1)(2).
Author information:
(1)Chinese Academy of Sciences Key Laboratory for Health Informatics, Shenzhen
Institutes of Advanced Technology, Shenzhen, China.
(2)Joint Engineering Research Center for Health Big Data Intelligent Analysis
Technology, Shenzhen Institutes of Advanced Technology, Chinese Academy of
Sciences, Shenzhen, China.
(3)State Key Lab of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union
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Medical College, Beijing, China.
OBJECTIVE: Continuous blood pressure (BP) provides valuable information for the
disease management of patients with arrhythmias. The traditional intra-arterial
method is too invasive for routine healthcare settings, whereas cuff-based
devices are inferior in reliability and comfortable for long-term BP monitoring
during arrhythmias. The study aimed to investigate an indirect method for
continuous and cuff-less BP estimation based on electrocardiogram (ECG) and
photoplethysmogram (PPG) signals during arrhythmias and to test its reliability
for the determination of BP using invasive BP (IBP) as reference.
METHODS: Thirty-five clinically stable patients (15 with ventricular arrhythmias
and 20 with supraventricular arrhythmias) who had undergone radiofrequency

ablation were enrolled in this study. Their ECG, PPG, and femoral arterial IBP
signals were simultaneously recorded with a multi-parameter monitoring system.
Fifteen features that have the potential ability in indicating beat-to-beat BP
changes during arrhythmias were extracted from the ECG and PPG signals. Four
machine learning algorithms, decision tree regression (DTR), support vector
machine regression (SVR), adaptive boosting regression (AdaboostR), and random
forest regression (RFR), were then implemented to develop the BP models.
RESULTS: The results showed that the mean value ± standard deviation of root
mean square error for the estimated systolic BP (SBP), diastolic BP (DBP) with
the RFR model against the reference in all patients were 5.87 ± 3.13 and 3.52 ±
1.38 mmHg, respectively, which achieved the best performance among all the
models. Furthermore, the mean error ± standard deviation of error between the
estimated SBP and DBP with the RFR model against the reference in all patients
were -0.04 ± 6.11 and 0.11 ± 3.62 mmHg, respectively, which complied with the
Association for the Advancement of Medical Instrumentation and the British
Hypertension Society (Grade A) standards.
CONCLUSION: The results indicated that the utilization of ECG and PPG signals
has the potential to enable cuff-less and continuous BP estimation in an
indirect way for patients with arrhythmias.
Copyright © 2020 Liu, Zhou, Li, Tang and Miao.
DOI: 10.3389/fphys.2020.575407
PMCID: PMC7509183
PMID: 33013491
24. Artif Intell Med. 2019 Jun;97:143-151. doi: 10.1016/j.artmed.2018.12.005.

Epub
2018 Dec 23.
A novel dynamical approach in continuous cuffless blood pressure estimation
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based on ECG and PPG signals.
Sharifi I(1), Goudarzi S(2), Khodabakhshi MB(3).
Author information:
(1)Biomedical Research Center, Baqiyatallah University of Medical Science,
Tehran, Iran.
(2)Biomedical Engineering Department, Amirkabir University of Technology,
Tehran, 15875-4413, Iran.
(3)Biomedical Engineering Department, Hamedan University of Technology, Hamedan,
6516913733, Iran. Electronic address: [email protected].
Continuous cuffless blood pressure (BP) monitoring has attracted much interest
in finding the ideal treatment of diseases and the prevention of premature
death. This paper presents a novel dynamical method, based on pulse transit time
(PTT) and photoplethysmogram intensity ratio (PIR), for the continuous cuffless
BP estimation. By taking the advantages of both the modeling and the prediction
approaches, the proposed framework effectively estimates diastolic BP (DBP),
mean BP (BP), and systolic BP (SBP). Adding past states of the cardiopulmonary
system as well as present states of the cardiac system to our model caused two
main improvements. First, high accuracy of the method in the beat to beat BP
estimation. Second, notwithstanding noticeable BP changes, the performance of
the model is preserved over time. The experimental setup includes comparative
studies on a large, standard dataset. Moreover, the proposed method outperformed
the most recent and cited algorithms with improved accuracy.
Copyright © 2018 Elsevier B.V. All rights reserved.
DOI: 10.1016/j.artmed.2018.12.005
10.1109/EMBC44109.2020.9175635.
Unobtrusive Blood Pressure Estimation using Personalized Autoregressive Models.
Zheng Y, Liu Q, Poon C.
Cuffless and continuous blood pressure (BP) measurement using wearable devices
is of great clinical value and health monitoring importance. Pulse arrival time
(PAT) based technique was considered as one of the most promising methods for
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this purpose. Considering the dynamic and nonlinear relationship between BP, PAT
and other cardiovascular variables, this paper proposes for the first time to
use nonlinear autoregressive models with extra inputs (ARX) for BP estimation.
The models were first trained by the baseline data of all 25 subjects to
determine the model structure and then trained by individual data to obtain the
personalized model parameters. To assess the effects of the dynamic and
nonlinear factors, the data during water drinking and the first 5 minutes of
recovery after drinking were used to validate the four models: linear
regression, linear ARX, nonlinear regression and nonlinear ARX. The reference
BP, which were measured by Finometer, were increased by 36.7±10.5 mmHg for SBP
and 28.4 ±7.7 mmHg for DBP. This BP changes were best modelled by the nonlinear
ARX, with Mean ± SD differences of 5.6 ± 8.8 mmHg for SBP and 3.8 ±5.8 mmHg for
DBP. The study also showed that nonlinear factor significantly reduced the root
mean square error (RSME) by about 50%, i.e., from 20.4 to 10.7 mmHg for SBP and
13.3 to 7.3 mmHg for DBP during drinking. While the effects of dynamic factors
were not as significant as nonlinear factors, especially after introducing
nonlinear factors.
DOI: 10.1109/EMBC44109.2020.9175635
26. Sci Rep. 2017 Sep 14;7(1):11554. doi: 10.1038/s41598-017-11507-3.
Pulse Transit Time Based Continuous Cuffless Blood Pressure Estimation: A New
Extension and A Comprehensive Evaluation.
Ding X(1), Yan BP(2), Zhang YT(1)(3), Liu J(1), Zhao N(1), Tsang HK(4).
Author information:
(1)Department of Electronic Engineering, The Chinese University of Hong Kong,
Hong Kong, China.
(2)Department of Medicine and Therapeutics, The Chinese University of Hong Kong,
Hong Kong, China.

(3)Yuan-Ting Zhang is with Key Laboratory for Health Informatics of the Chinese
Academy of Sciences (HICAS), Shenzhen Institutes of advanced technology,
Shenzhen, China.
(4)Department of Electronic Engineering, The Chinese University of Hong Kong,
Hong Kong, China. [email protected].
Cuffless technique enables continuous blood pressure (BP) measurement in an

unobtrusive manner, and thus has the potential to revolutionize the conventional
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cuff-based approaches. This study extends the pulse transit time (PTT) based
cuffless BP measurement method by introducing a new indicator - the
photoplethysmogram (PPG) intensity ratio (PIR). The performance of the models
with PTT and PIR was comprehensively evaluated in comparison with six models
that are based on sole PTT. The validation conducted on 33 subjects with and
without hypertension, at rest and under various maneuvers with induced BP
changes, and over an extended calibration interval, respectively. The results
showed that, comparing to the PTT models, the proposed methods achieved better
accuracy on each subject group at rest state and over 24 hours calibration
interval. Although the BP estimation errors under dynamic maneuvers and over
extended calibration interval were significantly increased for all methods, the
proposed methods still outperformed the compared methods in the latter
situation. These findings suggest that additional BP-related indicator other
than PTT has added value for improving the accuracy of cuffless BP measurement.
This study also offers insights into future research in cuffless BP measurement
for tracking dynamic BP changes and over extended periods of time.
DOI: 10.1038/s41598-017-11507-3
PMCID: PMC5599606
Conflict of interest statement: The authors declare that they have no competing
interests.
10.1109/EMBC.2018.8512829.
Features Extraction for Cuffless Blood Pressure Estimation by Autoencoder from

Photoplethysmography.
Shimazaki S, Bhuiyan S, Kawanaka H, Oguri K.
Several studies have been proposed to estimate blood pressure (BP) with cuffless
devices using only a Photoplethysmograph (PPG) sensor on the basis of the

physiological knowledge that the PPG changes depend on the state of the
cardiovascular system. In these studies, machine learning algorithms were used
to extract various features from the wave height and the elapsed time from the
rising point of the pulse wave to feature points have been used to estimate the
BP. However, the accuracy is still not adequate to be used as medical equipment
because their features cannot express fully information of the pulse waveform
which changes according to the BP. And, no other effective knowledge about the
pulse waveform for estimating BP has been found yet. Therefore, in this study,
we focus on the autoencoder which can extract complex features and can add new
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features of the pulse waveform for estimating the BP. By using autoencoder, we
extracted 100 features from the coupling signal of the pulse wave and from its
first-order differentiation and second-order differentiation. The result of
examination with 1363 test subjects show that the correlation coefficients and
the standard deviation of the difference between the measured BP and the
estimated BP got improved from R = 0.67, SD = 13.97 without autoencoder to R =
0.78, SD = 11.86 with autoencoder.
DOI: 10.1109/EMBC.2018.8512829
28. Sci Rep. 2020 Jan 29;10(1):1410. doi: 10.1038/s41598-020-58367-y.
Blood pressure estimation based on pulse rate variation in a certain period.
Hayase T(1).
Author information:
(1)Institute of Fluid Science, Tohoku University, 2-1-1 Katahira, Sendai,
980-8577, Japan. [email protected].
Availability of daily continuous blood pressure (DCBP) has a strong impact to

realization of healthy society. However, existing methods to obtain blood
pressure of cuff type and cuff-less types utilizing correlation with pulse
waveform, pulse transit time or pulse rate; or computation of circulation model
are not suitable to obtain DCBP. Here we implemented a method based on a simple
circulatory system model using pulse rate measurement to overcome the
limitations, and showed that it provides appropriate estimation of DCBP. The
present model consists of a circulatory dynamic system model and an inverse
model of a circulatory control system with input of pulse rate and six model
parameters representing standard pulse rate, elasticity of systemic arteries,
peripheral vascular resistance, and characteristics of resistance and stroke
volume control. Validity of the DCBP estimation method was examined by
preliminary experiment for one subject in four days and that for four subjects
in one day. DCBP estimation was performed with 24-hour pulse rate measurement by
a wearable device and sphygmomanometer measurement for parameter determination

and verification. Mean absolute errors in systolic/diastolic pressures were
appropriate ones for preliminary experiments with 9.4/6.4 mmHg in four days and
7.3/5.9 mmHg in five subjects.
DOI: 10.1038/s41598-020-58367-y
PMCID: PMC6989518
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Conflict of interest statement: The authors declare no competing interests.
29. Med Biol Eng Comput. 2021 Jun 3. doi: 10.1007/s11517-021-02362-6. Online
ahead
of print.
Learning and non-learning algorithms for cuffless blood pressure measurement: a

review.
Agham ND(1), Chaskar UM(2).
Author information:
(1)College of Engineering Pune, Wellesely Rd, Pune, 411005, India.
[email protected].
(2)College of Engineering Pune, Wellesely Rd, Pune, 411005, India.
The machine learning approach has gained a significant attention in the

healthcare sector because of the prospect of developing new techniques for
medical devices and handling the critical database of chronic diseases. The
learning approach has potential to analyze complex medical data, disease
diagnosis, and patient monitoring system, and to monitor e-health record.
Non-invasive cuffless blood pressure (CLBP) measurement secured a significant
position in the patient monitoring system. From a few recent decades, the
importance of cuffless technology has been perceived towards continuous
monitoring of blood pressure (BP) and supplementary efforts have been made
towards its continuous monitoring. However, the optimal method that measures BP
unambiguously and continuously has not yet emerged along with issues like
calibration time, accuracy and long-term estimation of BP with miniaturizing
hardware. The present study provides an insight into several learning algorithms
along with their feature selection models. Various challenges and future
improvements towards the current state of machine learning in healthcare
industries are discussed in the present review. The bottom line of this study is
to provide a comprehensive perspective of the machine learning approach of CLBP

for the generation of highly precise predictive models for continuous BP
measurement.
DOI: 10.1007/s11517-021-02362-6
PMID: 34085135
30. Front Cardiovasc Med. 2019 Apr 30;6:40. doi: 10.3389/fcvm.2019.00040.
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eCollection 2019.
Cuff-Less Methods for Blood Pressure Telemonitoring.
Bard DM(1)(2), Joseph JI(2), van Helmond N(2)(3).
Author information:
(1)Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA,
United States.
(2)Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson
University, Philadelphia, PA, United States.

(3)Department of Anesthesiology, Cooper Medical School of Rowan University,
Cooper University Hospital, Camden, NJ, United States.
Blood pressure telemonitoring (BPT) is a telemedicine strategy that uses a

patient's self-measured blood pressure (BP) and transmits this information to
healthcare providers, typically over the internet. BPT has been shown to improve
BP control compared to usual care without remote monitoring. Traditionally, a

cuff-based monitor with data communication capabilities has been used for BPT;
however, cuff-based measurements are inconvenient and cause discomfort, which
has prevented the widespread use of cuff-based monitors for BPT. The development
of new technologies which allow for remote BP monitoring without the use of a
cuff may aid in more extensive adoption of BPT. This would enhance patient
autonomy while providing physicians with a more complete picture of their
patient's BP profile, potentially leading to improved BP control and better
long-term clinical outcomes. This mini-review article aims to: (1) describe the
fundamentals of current techniques in cuff-less BP measurement; (2) present
examples of commercially available cuff-less technologies for BPT; (3) outline
challenges with current methodologies; and (4) describe potential future
directions in cuff-less BPT development.
DOI: 10.3389/fcvm.2019.00040
PMCID: PMC6502966
PMID: 31157236
10.1109/EMBC.2019.8857304.
Cuff-less and Calibration-free Blood Pressure Estimation Using Convolutional

Autoencoder with Unsupervised Feature Extraction.
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Zhang J, Wu D, Li Y.
Monitoring blood pressure (BP) in people's daily life in an unobtrusive way is

of great significance to prevent cardiovascular disease and its complications.
However, most of the current cuff-less BP estimation methods still suffer from
two drawbacks including calibration and tedious feature selection. In this
study, we first attempt to validate the feasibility of convolutional autoencoder
(CAE) to estimate continuous BP without calibration and hand-crafted feature

extraction. 62 subjects were recruited in this experiment. We first trained the
CAE on all the data to extract the unsupervised features. Then, we trained a
regressor to estimate BP values using the features learning from the CAE.
10-fold cross-validation tests were used to examine the performance of our
models. Finally, it has been demonstrated that the accuracy of the predicted BP
satisfied the Grade B standard of British Hypertension Society. Due to its
calibration-free and unsupervised feature learning ability from the collected
signal, the proposed method has high prospects for application in wearable BP
monitoring device.
DOI: 10.1109/EMBC.2019.8857304
32. Sensors (Basel). 2020 Jun 1;20(11):3127. doi: 10.3390/s20113127.
Estimating Blood Pressure from the Photoplethysmogram Signal and Demographic

Features Using Machine Learning Techniques.
Chowdhury MH(1), Shuzan MNI(1), Chowdhury MEH(2), Mahbub ZB(3), Uddin MM(3),
Khandakar A(2)(3), Reaz MBI(4).
Author information:
(1)Department of Electrical and Computer Engineering, North South University,
Dhaka 1229, Bangladesh.
(2)Department of Electrical Engineering, Qatar University, Doha 2713, Qatar.
(3)Department of Mathematics and Physics, North South University, Dhaka 1229,
Bangladesh.
(4)Department of Electrical, Electronic & Systems Engineering, Universiti
Kebangsaan Malaysia, Bangi Selangor 43600, Malaysia.
Hypertension is a potentially unsafe health ailment, which can be indicated

directly from the blood pressure (BP). Hypertension always leads to other health
complications. Continuous monitoring of BP is very important; however,
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cuff-based BP measurements are discrete and uncomfortable to the user. To
address this need, a cuff-less, continuous, and noninvasive BP measurement
system is proposed using the photoplethysmograph (PPG) signal and demographic
features using machine learning (ML) algorithms. PPG signals were acquired from
219 subjects, which undergo preprocessing and feature extraction steps. Time,
frequency, and time-frequency domain features were extracted from the PPG and
their derivative signals. Feature selection techniques were used to reduce the
computational complexity and to decrease the chance of over-fitting the ML
algorithms. The features were then used to train and evaluate ML algorithms. The
best regression models were selected for systolic BP (SBP) and diastolic BP
(DBP) estimation individually. Gaussian process regression (GPR) along with the
ReliefF feature selection algorithm outperforms other algorithms in estimating
SBP and DBP with a root mean square error (RMSE) of 6.74 and 3.59, respectively.
This ML model can be implemented in hardware systems to continuously monitor BP

and avoid any critical health conditions due to sudden changes.
DOI: 10.3390/s20113127
PMCID: PMC7309072
33. IEEE Trans Biomed Eng. 2016 May;63(5):964-972. doi:

10.1109/TBME.2015.2480679.
Epub 2015 Sep 22.
Continuous Cuffless Blood Pressure Estimation Using Pulse Transit Time and
Photoplethysmogram Intensity Ratio.
Ding XR, Zhang YT, Liu J, Dai WX, Tsang HK.
Pulse transit time (PTT) has attracted much interest for cuffless blood pressure
(BP) measurement. However, its limited accuracy is one of the main problems
preventing its widespread acceptance. Arterial BP oscillates mainly at high
frequency (HF) because of respiratory activity, and at low frequency (LF)
because of vasomotor tone. Prior studies suggested that PTT can track BP
variation in HF range, but was inadequate to follow the LF variation, which is
probably the main reason for its unsatisfactory accuracy. This paper presents a
new indicator, the photoplethysmogram intensity ratio (PIR), which can be
affected by changes in the arterial diameter, and, thus, trace the LF variation
of BP. Spectral analysis of BP, PTT, PIR, and respiratory signal confirmed that
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PTT was related to BP in HF at the respiratory frequency, while PIR was
associated with BP in LF range. We, therefore, develop a novel BP estimation
algorithm by using both PTT and PIR. The proposed algorithm was validated on 27
healthy subjects with continuous Finapres BP as reference. The results showed
that the mean ± standard deviation (SD) for the estimated systolic, diastolic,
and mean BP with the proposed method against reference were -0.37 ±5.21, -0.08
±4.06, -0.18 ±4.13 mmHg, and mean absolute difference (MAD) were 4.09, 3.18,
3.18 mmHg, respectively. Furthermore, the proposed method outperformed the two
most cited PTT algorithms for about 2 mmHg in SD and MAD. These results
demonstrated that the proposed BP model using PIR and PTT can estimate
continuous BP with improved accuracy.
DOI: 10.1109/TBME.2015.2480679
34. Technol Health Care. 2020;28(S1):217-227. doi: 10.3233/THC-209022.
Identification of blood pressure reflecting personalized traits using bilateral

photoplethysmography.
Shin YS.
BACKGROUND: Blood pressure (BP) is currently diagnosed by cuff-based devices,

which are inconvenient and provide discontinuous measurements.
Photoplethysmography (PPG)-based cuffless techniques have recently been used to
accurately estimate both systolic BP (SBP) and diastolic BP (DBP). However, it
is difficult to use these SBP and DBP estimations to reflect the personalized
traits in the peripheral vascular condition; thus, their accuracy is limited.
OBJECTIVE: The purpose of this study is to describe a technique that can be
distinguished simply among three BP categories (normotensive, prehypertensive,
and hypertensive) and reflect individual traits using PPG only.
METHODS: We measured BP over 120 s using the fingers of 105 subjects. The PPG
waveforms varied in size and amplitude over time. Therefore, normalization for
uniform features for individual traits was done after the extracted waveforms
were divided into multiple windows. The feature is determined by the lowest
amplitude in the waveform within each divided window. The features have been
applied to distinguish three BP categories using the first-eigenvector (1-EV)
and second-eigenvector (2-EV) in linear discriminant analysis.
RESULTS: The best decision boundary for each BP category was estimated using
1-EV (-0.02 to +0.02) and 2-EV (>+0.02) in the hypertensive category, 1-EV (< 0)
and 2-EV (⩽+0.02) in the prehypertensive category, and 1-EV (⩾-0.02) and 2-EV
(⩽+0.02) in the normotensive category. The overlap range with 1-EV (-0.02 to 0)
and 2-EV (⩽+0.02) in particular accurately reflected individual traits.
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CONCLUSION: Discrimination among the three BP categories reflecting individual
traits was successfully achieved using PPG. This method could improve
limitations of cuff-based techniques.
DOI: 10.3233/THC-209022
PMCID: PMC7369108
Conflict of interest statement: None to report.
35. Proc ACM Interact Mob Wearable Ubiquitous Technol. 2017 Sep;1(3):40. doi:
10.1145/3130905.
SeismoWatch: Wearable Cuffless Blood Pressure Monitoring Using Pulse Transit

Time.
Carek AM(1), Conant J(1), Joshi A(1), Kang H(1), Inan OT(1).
Author information:
(1)Georgia Institute of Technology.
The current norm for measuring blood pressure (BP) at home is using an automated
BP cuff based on oscillometry. Despite providing a viable and familiar method of
tracking BP at home, oscillometric devices can be both cumbersome and inaccurate
with the inconvenience of the hardware typically limiting measurements to once

or twice per day. To address these limitations, a wrist-watch BP monitor was
developed to measure BP through a simple maneuver: holding the watch against the
sternum to detect micro-vibrations of the chest wall associated with the

heartbeat. As a pulse wave propagates from the heart to the wrist, an
accelerometer and optical sensor on the watch measure the travel time - pulse
transit time (PTT) - to estimate BP. In this paper, we conducted a study to test
the accuracy and repeatability of our device. After calibration, the diastolic
pressure estimations reached a root-mean-square error of 2.9 mmHg. The
watch-based system significantly outperformed (p<0.05) conventional pulse
arrival time (PAT) based wearable blood pressure estimations - the most commonly
used method for wearable BP sensing in the existing literature and commercial
devices. Our device can be a convenient means for wearable BP monitoring outside
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of clinical settings in both health-conscious and hypertensive populations.1.
DOI: 10.1145/3130905
PMCID: PMC6292433
PMID: 30556049
36. Biomed Eng Lett. 2019 Feb 18;9(1):37-52. doi: 10.1007/s13534-019-00096-x.

eCollection 2019 Feb.
Pulse transit time technique for cuffless unobtrusive blood pressure

measurement: from theory to algorithm.
Ding X(1), Zhang YT(2).
Author information:
(1)1Department of Engineering Science, Institute of Biomedical Engineering,
University of Oxford, Oxford, UK.
(2)2Department of Biomedical Engineering, City University of Hong Kong, Hong
Kong, China.
Cuffless technique holds great promise to measure blood pressure (BP) in an

unobtrusive way, improving diagnostics and monitoring of hypertension and its
related cardiovascular diseases, and maximizing the independence and
participation of individual. Pulse transit time (PTT) has been the most commonly
employed techniques for cuffless BP estimation. Many studies have been conducted
to explore its feasibility and validate its performance in the clinical

settings. However, there is still issues and challenges ahead before its wide
application. This review will investigate the understanding and development of
the PTT technique in depth, with a focus on the physiological regulation of
arterial BP, the relationship between PTT and BP, and the summaries of the
PTT-based models for BP estimation.
DOI: 10.1007/s13534-019-00096-x
PMCID: PMC6431352
PMID: 30956879
Conflict of interest statement: All authors declare to have no conflict of

interests.This article does not contain any studies with human participants or
animals performed by any of the authors.Not applicable.
37. Sci Rep. 2021 Jan 13;11(1):1143. doi: 10.1038/s41598-020-80905-x.
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Improved agreement and diagnostic accuracy of a cuffless 24-h blood pressure

measurement device in clinical practice.
Socrates T(1), Krisai P(2)(3), Vischer AS(4), Meienberg A(4), Mayr M(4), Burkard
T(4)(2).
Author information:
(1)Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of
Excellence, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
[email protected].
(2)Department of Cardiology, University Hospital Basel, Basel, Switzerland.
(3)Cardiovascular Research Institute Basel, University Hospital Basel, Basel,
Switzerland.
Excellence, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
A cuffless blood pressure (BP) device (TestBP) using pulse transit time is in
clinical use, but leads to higher BP values compared to a cuff-based 24 h-BP
reference device (RefBP). We evaluated the impact of a recent software update on
BP results and TestBP's ability to differentiate between normo- and

hypertension. 71 individuals had TestBP (Somnotouch-NIBP) and RefBP measurements
simultaneously performed on either arm. TestBP results with software version

V1.5 were compared to V1.4 and RefBP. Mean 24 h (± SD) BP for the RefBP,
TestBP-V1.4 and TestBP-V1.5 were systolic 134.0 (± 17.3), 140.8 (± 20) and 139.1
(± 20) mmHg, and diastolic 79.3 (± 11.7), 85.8 (± 14.1) and 83.5 (± 13.0) mmHg,
respectively (p-values < 0.001). TestBP-V1.5 area under the curve (95%
confidence interval) versus RefBP for hypertension detection was 0.92 (0.86;
0.99), 0.94 (0.88; 0.99) and 0.77 (0.66; 0.88) for systolic and 0.92 (0.86;
0.99), 0.92 (0.85; 0.99) and 0.84 (0.74; 0.94) for diastolic 24 h, awake and
asleep BP respectively. TestBP-V1.5 detected elevated systolic/diastolic mean
24 h-BP with a 95%/90% sensitivity and 65%/70% specificity. Highest Youden's
Index was systolic 133 (sensitivity 95%/specificity 80%) and diastolic 87 mmHg
(sensitivity 81%/specificity 98%). The update improved the agreement to RefBP.
TestBP was excellent for detecting 24 h and awake hypertensive BP values but not
for asleep BP values.
DOI: 10.1038/s41598-020-80905-x
PMCID: PMC7806663
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PMID: 33441915
Conflict of interest statement: The authors declare no competing interests.
10.1109/EMBC.2019.8857373.
A Novel Method for Calibration-Based Cuff-Less Blood Pressure Estimation.
Li Z, Yan C, Zhao W, Hu J, Jia D, Wang H, You T.
Cuff-less blood pressure estimation technology is useful for cardiovascular

disease monitoring. However, without calibration, cuff-less blood pressure
estimation is hard to achieve clinical acceptable performance. The traditional
methods are always calibrated with retraining. With the increases of the
parameters number, the cost of model retraining increases several times. So we
propose a novel blood pressure estimation method, which can be calibrated with
reference inputs rather than with retraining. The experiment results suggest
that the method we proposed can achieve clinical performance (SBP:-0.004 ± 5.869
mmHg, DBP:-0.004±4.511 mmHg) with low calibration cost.
DOI: 10.1109/EMBC.2019.8857373
39. Stud Health Technol Inform. 2016;224:84-9.
Smartphone-based Continuous Blood Pressure Measurement Using Pulse Transit Time.
Gholamhosseini H(1), Meintjes A(1), Baig M(1), Linden M(2).
Author information:
(1)School of Engineering, Computer and Mathematical Sciences, Auckland
University of Technology, New Zealand.
(2)School of Innovation, Design and Engineering, Mälardalen University,
Västerås, Sweden.
The increasing availability of low cost and easy to use personalized medical
monitoring devices has opened the door for new and innovative methods of health
monitoring to emerge. Cuff-less and continuous methods of measuring blood
pressure are particularly attractive as blood pressure is one of the most
important measurements of long term cardiovascular health. Current methods of
noninvasive blood pressure measurement are based on inflation and deflation of a
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cuff with some effects on arteries where blood pressure is being measured. This
inflation can also cause patient discomfort and alter the measurement results.
In this work, a mobile application was developed to collate the
PhotoPlethysmoGramm (PPG) waveform provided by a pulse oximeter and the
electrocardiogram (ECG) for calculating the pulse transit time. This information
is then indirectly related to the user's systolic blood pressure. The developed
application successfully connects to the PPG and ECG monitoring devices using
Bluetooth wireless connection and stores the data onto an online server. The
pulse transit time is estimated in real time and the user's systolic blood
pressure can be estimated after the system has been calibrated. The
synchronization between the two devices was found to pose a challenge to this
method of continuous blood pressure monitoring. However, the implemented
continuous blood pressure monitoring system effectively serves as a proof of
concept. This combined with the massive benefits that an accurate and robust
continuous blood pressure monitoring system would provide indicates that it is
certainly worthwhile to further develop this system.
40. JMIR Mhealth Uhealth. 2020 Jul 20;8(7):e18012. doi: 10.2196/18012.
Mobile Personal Health Care System for Noninvasive, Pervasive, and Continuous
Blood Pressure Monitoring: Development and Usability Study.
Mena LJ(1), Félix VG(1), Ostos R(1), González AJ(1), Martínez-Peláez R(2),
Melgarejo JD(3), Maestre GE(4).
Author information:
(1)Academic Unit of Computing, Master Program in Applied Sciences, Universidad
Politecnica de Sinaloa, Mazatlan, Mexico.
(2)Faculty of Information Technology, Universidad de la Salle Bajío, Leon,
Mexico.
(3)Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven
Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
(4)Departments of Neurosciences and Human Genetics, and Rio Grande Valley
Alzheimer´s Disease Resource Center for Minority Aging Research, University of
Texas Rio Grande Valley, Brownsville, TX, United States.
BACKGROUND: Smartphone-based blood pressure (BP) monitoring using

photoplethysmography (PPG) technology has emerged as a promising approach to
empower users with self-monitoring for effective diagnosis and control of
hypertension.
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OBJECTIVE: This study aimed to develop a mobile personal health care system for
noninvasive, pervasive, and continuous estimation of BP level and variability,
which is user friendly for elderly people.
METHODS: The proposed approach was integrated by a self-designed cuffless,
calibration-free, wireless, and wearable PPG-only sensor and a native purposely
designed smartphone app using multilayer perceptron machine learning techniques
from raw signals. We performed a development and usability study with three
older adults (mean age 61.3 years, SD 1.5 years; 66% women) to test the
usability and accuracy of the smartphone-based BP monitor.
RESULTS: The employed artificial neural network model had good average accuracy
(>90%) and very strong correlation (>0.90) (P<.001) for predicting the reference
BP values of our validation sample (n=150). Bland-Altman plots showed that most
of the errors for BP prediction were less than 10 mmHg. However, according to
the Association for the Advancement of Medical Instrumentation and British
Hypertension Society standards, only diastolic blood pressure prediction met the
clinically accepted accuracy thresholds.

CONCLUSIONS: With further development and validation, the proposed system could
provide a cost-effective strategy to improve the quality and coverage of health
care, particularly in rural zones, areas lacking physicians, and areas with
solitary elderly populations.
©Luis J Mena, Vanessa G Félix, Rodolfo Ostos, Armando J González, Rafael

Martínez-Peláez, Jesus D Melgarejo, Gladys E Maestre. Originally published in
JMIR mHealth and uHealth (http://mhealth.jmir.org), 20.07.2020.
DOI: 10.2196/18012
PMCID: PMC7400045
Conflict of interest statement: Conflicts of Interest: None declared.
10.1109/EMBC.2019.8857108.
Novel Deep Convolutional Neural Network for Cuff-less Blood Pressure Measurement
Using ECG and PPG Signals.
Yan C, Li Z, Zhao W, Hu J, Jia D, Wang H, You T.
Cuff-less blood pressure (BP) is a potential method for BP monitoring because it
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is undisturbed and continuous monitoring. Existing cuff-less estimation methods
are easily influenced by signal noise and non-ideal signal morphology. In this
study we propose a novel well-designed Convolutional Neural Network (CNN) model
named Deep-BP for BP estimation task. The structure of Deep-BP can help to
capture more underlying data features associated with BP than handcrafted
features, thus improving the robustness and estimation accuracy. We carry out
experiments with and without calibration procedure in training stage to evaluate
the performance of new method in different application scenarios. The experiment
results show that the Deep-BP model achieves high accuracy and outperforms
existing methods, in the experiments both with and without calibration.
DOI: 10.1109/EMBC.2019.8857108
42. JACC Basic Transl Sci. 2017 Dec 25;2(6):631-642. doi:

10.1016/j.jacbts.2017.07.015. eCollection 2017 Dec.
Development and Validation of a Novel Cuff-Less Blood Pressure

Monitoring Device.
Watanabe N(1), Bando YK(1), Kawachi T(2), Yamakita H(2), Futatsuyama K(2), Honda
Y(2), Yasui H(1), Nishimura K(1), Kamihara T(1), Okumura T(1), Ishii H(1), Kondo
T(1), Murohara T(1).
Author information:
(1)Department of Cardiology, Nagoya University Graduate School of Medicine,
Nagoya, Japan.
(2)Healthcare Business Department, DENSO CORPORATION, Kariya, Japan.
Ordinary cuff-based blood pressure-monitoring devices remain a technical

limitation that disturbs activities of daily life. Here we report a novel system
for the cuff-less blood pressure estimation (CLB) that requires only 1 sensor
for photoplethysmography. The present study is the first report to validate and
assess the clinical application of the CLB in accordance with the latest
wearable device standard (issued by the Institute of Electrical and Electronics
Engineers, standard 1708-2014). Our CLB is expected to offer a flexible and
wearable device that permits blood pressure monitoring in more continuous and
stress-free settings.
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DOI: 10.1016/j.jacbts.2017.07.015
PMCID: PMC6058997
PMID: 30062178
10.1109/EMBC.2017.8037172.
Novel blood pressure estimation method using single photoplethysmography

feature.
Yang Chen, Shuo Cheng, Tong Wang, Ting Ma.
Continuous blood pressure (BP) monitoring has a significant meaning to the

prevention and early diagnosis of cardiovascular disease. However, existing
continuous BP monitoring approaches, especially cuff-less BP monitoring
approaches, are all contraptions which complex and huge computation required.
For example, for the most sophisticated cuff-less BP monitoring method using
pulse transit time (PTT), the simultaneous record of photoplethysmography (PPG)
signal and electrocardiography (ECG) are required, and various measurement of
characteristic points are needed. These issues hindered widely application of
cuff less BP measurement in the wearable devices. In this study, a novel BP
estimation method using single PPG signal feature was proposed and its
performance in BP estimation was also tested. The results showed that the new
approach proposed in this study has a mean error -0.91 ± 3.84 mmHg for SBP
estimation and -0.36 ± 3.36 mmHg for DBP estimation respectively. This approach
performed better than the traditional PTT based BP estimation, which mean error
for SBP estimation was -0.31 ± 4.78 mmHg, and for DBP estimation was -0.18 ±
4.32 mmHg. Further investigation revealed that this new BP estimation approach
only required measurement of one characteristic point, reducing much computation
when implementing. These results demonstrated that this new approach might be
more suitable implemented in the wearable BP monitoring devices.
DOI: 10.1109/EMBC.2017.8037172
44. Diagnostics (Basel). 2020 May 31;10(6):361. doi:

10.3390/diagnostics10060361.
Analyzing 24-Hour Blood Pressure Measurements with a Novel Cuffless Pulse

Transit Time Device in Clinical Practice-Does the Software for Heartbeat
Detection Matter?
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Kilian L(1), Krisai P(2)(3), Socrates T(1), Arranto C(4), Pfister O(2),
Meienberg A(1), Mayr M(1), Vischer AS(1), Burkard T(1)(2).
Author information:
Excellence, University Hospital Basel, 4031 Basel, Switzerland.
(2)Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland.
(3)Cardiovascular Research Institute Basel, University Hospital Basel, 4031
Basel, Switzerland.
(4)Department of Hematology, University Hospital Basel, 4031 Basel, Switzerland.
: Background: The Somnotouch-Non-Invasive-Blood-Pressure (NIBP) device delivers

raw data consisting of electrocardiography and photoplethysmography for
estimating blood pressure (BP) over 24 hours using pulse-transit-time. The
study's aim was to analyze the impact on 24-hour BP results when processing raw
data by two different software solutions delivered with the device.
METHODS: We used data from 234 participants. The Somnotouch-NIBP measurements
were analyzed using the Domino-light and Schiller software and compared. BP
values differing > 5 mmHg were regarded as relevant and explored for their
impact on BP classification (normotension vs. hypertension).
RESULTS: Mean (±standard deviation) absolute systolic/diastolic differences for
24-hour mean BP were 1.5 (±1.7)/1.1 (±1.3) mm Hg. Besides awake systolic BP (p =
0.022), there were no statistically significant differences in

systolic/diastolic 24-hour mean, awake, and asleep BP. Twenty four-hour mean BP
agreement (number (%)) between the software solutions within 5, 10, and 15 mmHg
were 222 (94.8%), 231 (98.7%), 234 (100%) for systolic and 228 (97.4%), 232
(99.1%), 233 (99.5%) for diastolic measurements, respectively. A BP difference
of >5 mmHg was present in 24 (10.3%) participants leading to discordant
classification in 4-17%.
CONCLUSION: By comparing the two software solutions, differences in BP are
negligible at the population level. However, at the individual level there are,
in a minority of cases, differences that lead to different BP classifications,
which can influence the therapeutic decision.
DOI: 10.3390/diagnostics10060361
PMCID: PMC7345122
PMID: 32486521
45. Biomed Eng Online. 2017 Feb 6;16(1):23. doi: 10.1186/s12938-017-0317-z.
Highly wearable cuff-less blood pressure and heart rate monitoring with
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single-arm electrocardiogram and photoplethysmogram signals.
Zhang Q(1), Zhou D(2)(3), Zeng X(3).
Author information:
(1)Departpment of Electrical Engineering, University of Texas at Dallas, 800 W
Campbell Rd, Richardson, TX, 75080, USA. [email protected].
(2)Departpment of Electrical Engineering, University of Texas at Dallas, 800 W
Campbell Rd, Richardson, TX, 75080, USA.
(3)Department of Microelectronics, Fudan University, 220 Handan Rd, Shanghai,
200433, China.
BACKGROUND: Long-term continuous systolic blood pressure (SBP) and heart rate
(HR) monitors are of tremendous value to medical (cardiovascular, circulatory
and cerebrovascular management), wellness (emotional and stress tracking) and
fitness (performance monitoring) applications, but face several major
impediments, such as poor wearability, lack of widely accepted robust SBP models
and insufficient proofing of the generalization ability of calibrated models.

METHODS: This paper proposes a wearable cuff-less electrocardiography (ECG) and
photoplethysmogram (PPG)-based SBP and HR monitoring system and many efforts are
made focusing on above challenges. Firstly, both ECG/PPG sensors are integrated
into a single-arm band to provide a super wearability. A highly convenient but
challenging single-lead configuration is proposed for weak single-arm-ECG
acquisition, instead of placing the electrodes on the chest, or two wrists.
Secondly, to identify heartbeats and estimate HR from the motion
artifacts-sensitive weak arm-ECG, a machine learning-enabled framework is
applied. Then ECG-PPG heartbeat pairs are determined for pulse transit time
(PTT) measurement. Thirdly, a PTT&HR-SBP model is applied for SBP estimation,
which is also compared with many PTT-SBP models to demonstrate the necessity to
introduce HR information in model establishment. Fourthly, the fitted SBP models
are further evaluated on the unseen data to illustrate the generalization

ability. A customized hardware prototype was established and a dataset collected
from ten volunteers was acquired to evaluate the proof-of-concept system.

RESULTS: The semi-customized prototype successfully acquired from the left upper
arm the PPG signal, and the weak ECG signal, the amplitude of which is only
around 10% of that of the chest-ECG. The HR estimation has a mean absolute error
(MAE) and a root mean square error (RMSE) of only 0.21 and 1.20 beats per min,
respectively. Through the comparative analysis, the PTT&HR-SBP models
significantly outperform the PTT-SBP models. The testing performance is
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1.63 ± 4.44, 3.68, 4.71 mmHg in terms of mean error ± standard deviation, MAE
and RMSE, respectively, indicating a good generalization ability on the unseen
fresh data.
CONCLUSIONS: The proposed proof-of-concept system is highly wearable, and its
robustness is thoroughly evaluated on different modeling strategies and also the
unseen data, which are expected to contribute to long-term pervasive

hypertension, heart health and fitness management.
DOI: 10.1186/s12938-017-0317-z
PMCID: PMC5294811
46. J Clin Med. 2019 Mar 11;8(3):337. doi: 10.3390/jcm8030337.
How Effective Is Pulse Arrival Time for Evaluating Blood Pressure? Challenges
and Recommendations from a Study Using the MIMIC Database.
Liang Y(1), Abbott D(2)(3), Howard N(4)(5), Lim K(6)(7), Ward R(8), Elgendi
M(9)(10)(11)(12).
Author information:
(1)School of Electrical and Computer Engineering, University of British
Columbia, Vancouver BC V6T 1Z4, Canada. [email protected].
(2)School of Electrical and Electronic Engineering, The University of Adelaide,
Adelaide SA 5005, Australia. [email protected].
(3)Centre for Biomedical Engineering, The University of Adelaide, Adelaide SA
5005, Australia. [email protected].
(4)Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3
9DU, UK. [email protected].
(5)Howard Brain Sciences Foundation, Providence, RI 02906, USA.
[email protected].
(6)Faculty of Medicine, University of British Columbia, Vancouver BC V1Y 1T3,
Canada. [email protected].
(7)BC Children's & Women's Hospital, Vancouver BC V6H 3N1, Canada.
[email protected].
(10)Howard Brain Sciences Foundation, Providence, RI 02906, USA.
[email protected].
(11)Faculty of Medicine, University of British Columbia, Vancouver BC V1Y 1T3,
Canada. [email protected].
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(12)BC Children's & Women's Hospital, Vancouver BC V6H 3N1, Canada.
[email protected].
Cardiovascular disease (CVD) is the number one cause of non-infectious morbidity
and mortality in the world. The detection, measurement, and management of high
blood pressure play an essential role in the prevention and control of CVDs.
However, owing to the limitations and discomfort of traditional blood pressure
(BP) detection techniques, many new cuff-less blood pressure approaches have
been proposed and explored. Most of these involve arterial wave propagation
theory, which is based on pulse arrival time (PAT), the time interval needed for
a pulse wave to travel from the heart to some distal place on the body, such as
the finger or earlobe. For this study, the Medical Information Mart for
Intensive Care (MIMIC) database was used as a benchmark for PAT analysis. Many
researchers who use the MIMIC database make the erroneous assumption that all
the signals are synchronized. Therefore, we decided to investigate the
calculation of PAT intervals in the MIMIC database and check its usefulness for
evaluating BP. Our findings have important implications for the future use of
the MIMIC database, especially for BP evaluation.
DOI: 10.3390/jcm8030337
PMCID: PMC6462898
PMID: 30862031
47. Annu Int Conf IEEE Eng Med Biol Soc. 2016 Aug;2016:607-610. doi:
10.1109/EMBC.2016.7590775.
Cuff-less PPG based continuous blood pressure monitoring: a smartphone based

approach.
Gaurav A, Maheedhar M, Tiwari VN, Narayanan R.
Cuff-less estimation of systolic (SBP) and diastolic (DBP) blood pressure is an

efficient approach for non-invasive and continuous monitoring of an individual's
vitals. Although pulse transit time (PTT) based approaches have been successful
in estimating the systolic and diastolic blood pressures to a reasonable degree
of accuracy, there is still scope for improvement in terms of accuracies.
Moreover, PTT approach requires data from sensors placed at two different
locations along with individual calibration of physiological parameters for
deriving correct estimation of systolic and diastolic blood pressure (BP) and
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hence is not suitable for smartphone deployment. Heart Rate Variability is one
of the extensively used non-invasive parameters to assess cardiovascular
autonomic nervous system and is known to be associated with SBP and DBP
indirectly. In this work, we propose a novel method to extract a comprehensive
set of features by combining PPG signal based and Heart Rate Variability (HRV)
related features using a single PPG sensor. Further, these features are fed into
a DBP feedback based combinatorial neural network model to arrive at a common

weighted average output of DBP and subsequently SBP. Our results show that using
this current approach, an accuracy of ±6.8 mmHg for SBP and ±4.7 mmHg for DBP is
achievable on 1,750,000 pulses extracted from a public database (comprising 3000
people). Since most of the smartphones are now equipped with PPG sensor, a
mobile based cuff-less BP estimation will enable the user to monitor their BP as
a vital parameter on demand. This will open new avenues towards development of
pervasive and continuous BP monitoring systems leading to an early detection and
prevention of cardiovascular diseases.
DOI: 10.1109/EMBC.2016.7590775
10.1109/EMBC44109.2020.9176221.
Validation of Pulse Transit Time Based Blood Pressure Estimation on Atrial

Fibrillation Patients.
Chen Y, Huang S, Wang T, Ma T.
Pulse transit time (PTT) based continuous cuff-less blood pressure (BP)
monitoring has attracted wide interests owing to its potential in improving the
control and early prevention for cardiovascular diseases. However, it is still
impractical in large-scale clinical application due to the concern of BP
measurement accuracy. Since such approach strongly relies on the PTT-BP model
under certain theoretical assumptions, the accuracy would be affected by the
vessel properties alterations induced by cardiovascular disorders. Atrial
fibrillation (AF) is one of the most common cardiac diseases which often coexist
with hypertension. The present study sought to examine the Impact of AF on the
PTT and BP， validate the capability of PTT based cuff-less methods on AF
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patients. By investigating the PTT and BP on 74 critically ill patients with AF,
we found that parameters including PTT, R-R interval and diastolic BP (DBP) were
significantly changed when AF occurs, while the systolic BP (SBP) value and
photoplethysmography intensity ratio (PIR) changed little. Further, by
performing two cuff-less BP estimation method, we found that the estimated
accuracy is decreased on PTT based method when AF occurs, but there is little
change on PIR based method. The findings demonstrated that the impact of AF on
PTT is significant, which would also influence the PTT-BP relationship. But the
PIR would still be a predictive factor for BP estimation for AF patients.
DOI: 10.1109/EMBC44109.2020.9176221
49. Sensors (Basel). 2020 Apr 13;20(8):2205. doi: 10.3390/s20082205.
A Revised Point-to-Point Calibration Approach with Adaptive Errors Correction to
Weaken Initial Sensitivity of Cuff-Less Blood Pressure Estimation.
Shao J(1), Shi P(1), Hu S(2), Yu H(1).
Author information:
(1)Institute of Rehabilitation Engineering and Technology, University of
Shanghai for Science and Technology, Shanghai 200093, China.
(2)Wolfson School of Mechanical, Electrical and Manufacturing Engineering,
Loughborough University, Loughborough, Leicestershire LE11 3TU, UK.
Initial calibration is a great challenge for cuff-less blood pressure (BP)

measurement. The traditional one point-to-point (oPTP) calibration procedure
only uses one sample/point to obtain unknown parameters of a specific model in a
calm state. In fact, parameters such as pulse transit time (PTT) and BP still
have slight fluctuations at rest for each subject. The conventional oPTP method
had a strong sensitivity in the selection of initial value. Yet, the initial
sensitivity of calibration has not been reported and investigated in cuff-less
BP motoring. In this study, a mean point-to-point (mPTP) paring calibration
method through averaging and balancing calm or peaceful states was proposed for
the first time. Thus, based on mPTP, a factor point-to-point (fPTP) paring
calibration method through introducing the penalty factor was further proposed
to improve and optimize the performance of BP estimation. Using the oPTP, mPTP,
and fPTP methods, a total of more than 100,000 heartbeat samples from 21 healthy
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subjects were tested and validated in the PTT-based BP monitoring technologies.
The results showed that the mPTP and fPTP methods significantly improved the
performance of estimating BP compared to the conventional oPTP method. Moreover,
the mPTP and fPTP methods could be widely popularized and applied, especially
the fPTP method, on estimating cuff-less diastolic blood pressure (DBP). To this
extent, the fPTP method weakens the initial calibration sensitivity of cuff-less
BP estimation and fills in the ambiguity for individualized calibration

procedure.
DOI: 10.3390/s20082205
PMCID: PMC7218878
50. IEEE J Biomed Health Inform. 2018 Jul;22(4):1068-1074. doi:

10.1109/JBHI.2017.2714674. Epub 2017 Jun 12.
Cuff-Less Blood Pressure Estimation Using Pulse Waveform Analysis and Pulse
Arrival Time.
Yoon YZ, Kang JM, Kwon Y, Park S, Noh S, Kim Y, Park J, Hwang SW, Young-Zoon
Yoon, Jae Min Kang, Yongjoo Kwon, Sangyun Park, Seungwoo Noh, Younho Kim, Jongae
Park, Sung Woo Hwang.
Using the massive MIMIC physiological database, we tried to validate pulse wave
analysis (PWA) based on multiparameters model whether it can continuously
estimate blood pressure (BP) values on single site of one hand. In addition, to
consider the limitation of insufficient data acquirement for home user, we used
pulse arrival time (PAT) driven BP information to determine the individual scale
factors of the PWA-BP estimation model. Experimental results indicate that the
accuracy of the average regression model has error standard deviations of mmHg
(PAT), mmHg (PWA) for SBP and mmHg (PAT), mmHg (PWA) for DBP on 23 subjects
over a 1 day period. We defined a local-model which is extracted regression
model from sparsely selected small dataset, contrast to full dataset for 24h
(average-model). The limit of BP estimation accuracy from the local-model of PWA
is lower than that of PAT-BP average-model. Whereas the error of the BP

estimation local-model was reduced using more data for scaling, it required more
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than four times the 1 min data extracted over the 12 h calibration period to
predict BP for 1 day. This study shows that PWA has possibility to estimate BP
value and PAT-driven BP information could be used to determine the individual
scale factors of the PWA-BP estimation model for home users.
DOI: 10.1109/JBHI.2017.2714674
10.1109/EMBC.2017.8036930.
Using a new PPG indicator to increase the accuracy of PTT-based continuous

cuffless blood pressure estimation.
Wan-Hua Lin, Hui Wang, Samuel OW, Guanglin Li.
Pulse transit time (PTT) has been identified as a potential indicator to

estimate blood pressure (BP) continuously and cufflessly in the previous
studies, but it is still unsatisfactory for clinical uses. In order to improve
the BP estimation accuracy, another candidate signal, photoplethysmogram (PPG)
has been used to estimate continuous BP. In this study, a new PPG indicator, the
intensity ratio of the first derivative wave of PPG (1st dPIR), was proposed and
a novel BP estimation algorithm by using both PTT and 1st dPIR was developed
with an attempt to further increase the BP estimation accuracy. The performance
of the proposed algorithm was examined and validated using the ECG and PPG
recordings from 22 healthy subjects when they performed both mental arithmetic
stress and Valsalva's manoeuvre tests that could induce their BP fluctuations.
The continuous Finapres® BP were measured with a finger cuff as a referenced BP
value. Our results showed that using the proposed BP estimation algorithm, the
grand absolute mean and standard deviation (SD) errors between the estimated and
referenced BP were 3.22±8.02 mmHg for systolic BP (SBP) and 3.13±4.82mmHg for
diastolic BP (DBP). It could achieve a decrease of 0.34±0.27 mmHg in SBP and
0.33±0.44 mmHg in DBP on the grand absolute mean and SD estimation errors in
comparison to the state-of-the-art PPT-based method. Findings from this study
suggest that the newly proposed PPG indicator would be promising for improving
the accuracy of current PTT-based continuous and cuffless BP estimation
algorithms.
DOI: 10.1109/EMBC.2017.8036930
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52. Proc Mach Learn Res. 2020 Aug;126:97-120.
Developing Personalized Models of Blood Pressure Estimation from Wearable

Sensors Data Using Minimally-trained Domain Adversarial Neural Networks.
Zhang L(1), Hurley NC(1), Ibrahim B(2), Spatz E(3), Krumholz HM(3), Jafari
R(4)(1)(2), Mortazavi BJ(1).
Author information:
(1)Department of Computer Science and Engineering, Texas A&M University, USA.
(2)Department of Electrical and Computer Engineering, Texas A&M University, USA.
(3)Yale School of Medicine, Yale University, USA.
(4)Department of Biomedical Engineering, Texas A&M University, USA.
Blood pressure monitoring is an essential component of hypertension management

and in the prediction of associated comorbidities. Blood pressure is a dynamic
vital sign with frequent changes throughout a given day. Capturing blood
pressure remotely and frequently (also known as ambulatory blood pressure
monitoring) has traditionally been achieved by measuring blood pressure at
discrete intervals using an inflatable cuff. However, there is growing interest
in developing a cuffless ambulatory blood pressure monitoring system to measure
blood pressure continuously. One such approach is by utilizing bioimpedance
sensors to build regression models. A practical problem with this approach is
that the amount of data required to confidently train such a regression model
can be prohibitive. In this paper, we propose the application of the
domain-adversarial training neural network (DANN) method on our multitask
learning (MTL) blood pressure estimation model, allowing for knowledge transfer
between subjects. Our proposed model obtains average root mean square error
(RMSE) of 4.80 ± 0.74 mmHg for diastolic blood pressure and 7.34 ± 1.88 mmHg for
systolic blood pressure when using three minutes of training data, 4.64 ± 0.60
mmHg and 7.10 ± 1.79 respectively when using four minutes of training data, and
4.48±0.57 mmHg and 6.79±1.70 respectively when using five minutes of training
data. DANN improves training with minimal data in comparison to both directly
training and to training with a pretrained model from another subject,
decreasing RMSE by 0.19 to 0.26 mmHg (diastolic) and by 0.46 to 0.67 mmHg
(systolic) in comparison to the best baseline models. We observe that four
minutes of training data is the minimum requirement for our framework to exceed
ISO standards within this cohort of patients.
PMCID: PMC7916101
PMID: 33649743
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53. Physiol Meas. 2018 Feb 28;39(2):025010. doi: 10.1088/1361-6579/aa996d.
Cuff-less blood pressure measurement from dual-channel photoplethysmographic

signals via peripheral pulse transit time with singular spectrum analysis.
Wang Y(1), Liu Z, Ma S.
Author information:
(1)School of Information and Electronics, Beijing Institute of Technology,
Beijing, People's Republic of China.
OBJECTIVE: This paper proposes an unobtrusive blood pressure (BP) measurement

system design with a motion artifact (MA) compensation strategy as a potential
surrogate to the traditional cuff-based sphygmomanometer for self-monitoring in
a less restricted environment.
APPROACH: A dual-channel photoplethysmographic signal acquisition system is
designed and implemented for cuff-less BP measurement based on the peripheral
pulse transit time (PPTT) acquired from the forearm and wrist. Comprising a
motion decision, singular spectrum analysis, PPTT calculation and BP
measurement, a novel approach is proposed to realize BP measurements and
suppress MA interference.
MAIN RESULTS: Compared with the reference BP recorded by a cuff-based
sphygmomanometer, our preliminary examinations on 30 subjects found that the
correlation coefficients for systolic BP estimation and diastolic BP estimation
were 0.75 and 0.78, and the mean absolute differences were 7.61 mmHg and 6.82
mmHg, respectively. Meanwhile, the proposed approach was compared with the other
most widely used pulse transit time (PTT) measuring methods and BP-PTT models.
All the results indicate that our work was highly effective in realizing the BP
measurement.
SIGNIFICANCE: The proposed system and approach have resulted in remarkable
progress in cuff-less BP measurements with MA removal, and have great potential
value in wearable applications without environmental restrictions.
DOI: 10.1088/1361-6579/aa996d
10.1109/EMBC.2018.8513364.
A Novel Calibration Procedure of Pulse Transit Time based Blood Pressure

measurement with Heart Rate and Respiratory Rate.
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Lui HW, Chow KL.
Pulse transit time (PTT) has been a promising non-invasive and cuff-less method
to measure blood pressure (BP). However, to achieve acceptable accuracy, subject
specific and frequent calibration is required to model the complex non-Iinear

dynamic between BP and PTT, limiting the practicality of PTT-based methods. The
BP-PTT relationship is often modelled by the Moens-Korteweg (M-K) equation.
Previous studies have found that the M-K equation is only able to model high
frequency variations of BP, with low frequency variations modulated by the
vasomotor tone, which is regulated by the sympathetic nervous system (SNS). In
this paper we present a novel calibration procedure that accounts for the
influence of the SNS on the BP-PTT relationship. This is achieved by identifying
the state of the SNS during calibration based on heart rate (HR), respiratory
rate (RR), and PTT itself. The performance of the proposed procedure has been
tested on 10 subjects over a period of 4 weeks. The results showed that the
measurement differences were 1.04 mmHg ± 6.88 mmHg, and -2.16mmHg ± 6.60 mmHg
for systolic and diastolic blood pressure, respectively. Furthermore, the
proposed procedure was found to make a significant improvement of measurement
precision when compared to the previous one-point calibration method,
demonstrating the potential of the new procedure for accurate long-term BP
tracking.
DOI: 10.1109/EMBC.2018.8513364
55. Annu Int Conf IEEE Eng Med Biol Soc. 2015;2015:398-401. doi:
10.1109/EMBC.2015.7318383.
Photoplethysmogram intensity ratio: A potential indicator for improving the

accuracy of PTT-based cuffless blood pressure estimation.
Ding XR, Zhang YT.
The most commonly used method for cuffless blood pressure (BP) measurement is
using pulse transit time (PTT), which is based on Moens-Korteweg (M-K) equation
underlying the assumption that arterial geometries such as the arterial diameter
keep unchanged. However, the arterial diameter is dynamic which varies over the
cardiac cycle, and it is regulated through the contraction or relaxation of the
vascular smooth muscle innervated primarily by the sympathetic nervous system.
This may be one of the main reasons that impair the BP estimation accuracy. In
this paper, we propose a novel indicator, the photoplethysmogram (PPG) intensity
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ratio (PIR), to evaluate the arterial diameter change. The deep breathing (DB)
maneuver and Valsalva maneuver (VM) were performed on five healthy subjects for
assessing parasympathetic and sympathetic nervous activities, respectively.
Heart rate (HR), PTT, PIR and BP were measured from the simultaneously recorded
electrocardiogram (ECG), PPG, and continuous BP. It was found that PIR increased
significantly from inspiration to expiration during DB, whilst BP dipped

correspondingly. Nevertheless, PIR changed positively with BP during VM. In
addition, the spectral analysis revealed that the dominant frequency component
of PIR, HR and SBP, shifted significantly from high frequency (HF) to low
frequency (LF), but not obvious in that of PTT. These results demonstrated that
PIR can be potentially used to evaluate the smooth muscle tone which modulates
arterial BP in the LF range. The PTT-based BP measurement that take into account
the PIR could therefore improve its estimation accuracy.
DOI: 10.1109/EMBC.2015.7318383
56. Zhongguo Yi Liao Qi Xie Za Zhi. 2015 Jul;39(4):285-7.
[Mobile Health: IEEE Standard for Wearable Cuffless Blood Pressure Measuring
Devices].
[Article in Chinese]
Zhou X, Wu W, Bao S.
IEEE Std 1708-2014 breaks through the traditional standards of cuff based blood
pressure measuring devices and establishes a normative definition of wearable
cuffless blood pressure measuring devices and the objective performance
evaluation of this kind of devices. This study firstly introduces the background
of the new standard. Then, the standard details will be described, and the
impact of cuffless blood pressure measuring devices with the new standard on
manufacturers and end users will be addressed.
57. Physiol Meas. 2021 Apr 15. doi: 10.1088/1361-6579/abf889. Online ahead of
print.
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Study of cuffless blood pressure estimation method based on multiple
physiological parameters.
Zhang Y(1), Zhou C(1), Huang Z(1), Ye X(2).
Author information:
(1)College of Biomedical Engineering and Instrument Science, Zhejiang
University, Hangzhou, Zhejiang, CHINA.
(2)College of Biomedical Engineering and Instrument Science, Zhejiang
University, Zhejiang Province ZheDa road 38#, Hangzhou, Zhejiang, 310027, CHINA.
OBJECTIVE: Non-invasive blood pressure measurement technologies have been widely
studied, but they still have the disadvantages of low accuracy, require frequent
calibration and limited subjects. This work considers the regulation of vascular
activity by the sympathetic nervous system and proposes a method for estimating
blood pressure using multiple physiological parameters.
APPROACH: The parameters used in the model consist Heart Rate Variability(HRV),
pulse transit time(PTT) and pulse wave morphology features extracted from ECG
and PPG signals. Through 4 classic machine learning algorithms, a hybrid data
set of 3337 subjects from two databases is evaluated to verify the ability of
cross-database migration. We also recommend an individual calibration procedure
to further improve the accuracy of the method.
MAIN RESULTS: The mean absolute error(MAE) and the root means square error(RMSE)
of the proposed algorithm is 10.03 and 14.45 mmHg for systolic blood
pressure(SBP), 5.35 and 8.35 mmHg for diastolic blood pressure(DBP). With
individual calibration, the MAE and standard deviation(SD) is -0.16±7.96(SBP)
and -0.13±4.50(DBP) mmHg, which satisfied the Advancement of
MedicalInstrumentation(AAMI) standard. Besides, the models are used to test
single databases to evaluate their performance on different data sources. The
overall performance of the Adaboost algorithm is better on the Multi-parameter
Intelligent Monitoring in Intensive Care Unit(MIMIC) database, the MAE between
its predicted value and true value reaches 6.6mmHg(SBP) and 3.12mmHg(DBP),
respectively.
SIGNIFICANCE: The proposed method considers the regulation of blood vessels and
the heart by the autonomic nervous system, verifies its effectiveness and
robustness across data sources, which is promising for improving the accuracy of
continuous and cuffless BP estimation.
© 2021 Institute of Physics and Engineering in Medicine.
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DOI: 10.1088/1361-6579/abf889
PMID: 33857923
58. Sensors (Basel). 2021 May 19;21(10):3525. doi: 10.3390/s21103525.
Cuffless Blood Pressure Measurement Using a Smartphone-Case Based ECG Monitor

with Photoplethysmography in Hypertensive Patients.
Sagirova Z(1), Kuznetsova N(2), Gogiberidze N(1), Gognieva D(2), Suvorov A(3),
Chomakhidze P(2), Omboni S(1)(4), Saner H(1)(5)(6), Kopylov P(2).
Author information:
(1)Department of Cardiology, Functional and Ultrasound Diagnostics of N.V.
Sklifosovsky, Institute for Clinical Medicine, I.M. Sechenov First Moscow State
Medical University, 119435 Moscow, Russia.
(2)Research Center "Digital Biodesign and Personalized Healthcare", I.M.
Sechenov First Moscow State Medical University, 119991 Moscow, Russia.
(3)Centre for Analysis of Complex Systems, I.M. Sechenov First Moscow State
Medical University, 119991 Moscow, Russia.
(4)Italian Institute of Telemedicine, 21048 Solbiate Arno, Italy.
(5)ARTORG Center for Biomedical Engineering Research, University of Bern, 3008
Bern, Switzerland.
(6)Institute for Social and Preventive Medicine, University of Bern, 3012 Bern,
Switzerland.
The availability of simple, accurate, and affordable cuffless blood pressure

(BP) devices has the potential to greatly increase the compliance with
measurement recommendations and the utilization of BP measurements for BP
telemonitoring. The aim of this study is to evaluate the correlation between
findings from routine BP measurements using a conventional sphygmomanometer with
the results from a portable ECG monitor combined with photoplethysmography (PPG)
for pulse wave registration in patients with arterial hypertension.

METHODS: The study included 500 patients aged 32-88 years (mean 64 ± 7.9 years).
Mean values from three routine BP measurements by a sphygmomanometer with cuff

were selected for comparison; within one minute after the last measurement, an
electrocardiogram (ECG) was recorded for 3 min in the standard lead I using a
smartphone-case based single-channel ECG monitor (CardioQVARK®-limited
responsibility company "L-CARD", Moscow, Russia) simultaneously with a PPG pulse
wave recording. Using a combination of the heart signal with the PPG, levels of
systolic and diastolic BP were determined based on machine learning using a
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previously developed and validated algorithm and were compared with
sphygmomanometer results.
RESULTS: According to the Bland-Altman analysis, SD for systolic BP was 3.63,
and bias was 0.32 for systolic BP. SD was 2.95 and bias was 0.61 for diastolic
BP. The correlation between the results from the sphygmomanometer and the
cuffless method was 0.89 (p = 0.001) for systolic and 0.87 (p = 0.002) for
diastolic BP.
CONCLUSION: Blood pressure measurements on a smartphone-case without a cuff are
encouraging. However, further research is needed to improve the accuracy and
reliability of clinical use in the majority of patients.
DOI: 10.3390/s21103525
PMCID: PMC8158773
Conflict of interest statement: All authors declare no conflict of interest.
59. Sci Rep. 2016 Dec 15;6:39273. doi: 10.1038/srep39273.
Weighing Scale-Based Pulse Transit Time is a Superior Marker of Blood Pressure

than Conventional Pulse Arrival Time.
Martin SL(1), Carek AM(2), Kim CS(1), Ashouri H(2), Inan OT(2), Hahn JO(1),
Mukkamala R(3).
Author information:
(1)Department of Mechanical Engineering, University of Maryland, College Park,
MD, USA.
(2)School of Electrical and Computer Engineering, Georgia Institute of
Technology, Atlanta, GA, USA.
(3)Department of Electrical and Computer Engineering, Michigan State University,
East Lansing, MI, USA.
Erratum in
Sci Rep. 2018 Oct 29;8(1):15838.
Pulse transit time (PTT) is being widely pursued for cuff-less blood pressure
(BP) monitoring. Most efforts have employed the time delay between ECG and
finger photoplethysmography (PPG) waveforms as a convenient surrogate of PTT.
However, these conventional pulse arrival time (PAT) measurements include the
pre-ejection period (PEP) and the time delay through small, muscular arteries
and may thus be an unreliable marker of BP. We assessed a bathroom weighing
scale-like system for convenient measurement of ballistocardiography and foot
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PPG waveforms - and thus PTT through larger, more elastic arteries - in terms of
its ability to improve tracking of BP in individual subjects. We measured "scale
PTT", conventional PAT, and cuff BP in humans during interventions that

increased BP but changed PEP and smooth muscle contraction differently. Scale
PTT tracked the diastolic BP changes well, with correlation coefficient of
-0.80 ± 0.02 (mean ± SE) and root-mean-squared-error of 7.6 ± 0.5 mmHg after a
best-case calibration. Conventional PAT was significantly inferior in tracking
these changes, with correlation coefficient of -0.60 ± 0.04 and
root-mean-squared-error of 14.6 ± 1.5 mmHg (p < 0.05). Scale PTT also tracked
the systolic BP changes better than conventional PAT but not to an acceptable
level. With further development, scale PTT may permit reliable, convenient
measurement of BP.
DOI: 10.1038/srep39273
PMCID: PMC5157040
Conflict of interest statement: OTI is a Scientific Advisor for, and has patents
licensed to, Physiowave, Inc., a company that is commercializing BCG-based

devices. All other authors declare no conflicts of interest.
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abstract-cufflessAN-set.

Cuffless Blood Pressure Estimation Algorithms for Continuous Health-Care

Kachuee M, Kiani MM, Mohammadzade H, Shabany M.

GOAL: Continuous blood pressure (BP) monitoring can provide invaluable

monitoring. This paper presents an efficient algorithm, based on the pulse

accuracy even further.

Association for the Advancement of Medical Instrumentation (AAMI) and the

2. Proc Natl Acad Sci U S A. 2018 Oct 30;115(44):11144-11149. doi:

Ma Y(1)(2), Choi J(3)(4)(5), Hourlier-Fargette A(3)(4)(5), Xue Y(3)(4)(6)(7),

and Technology, 34141 Daejeon, Republic of Korea.

Urbana-Champaign, Urbana, IL 61801.

Continuous monitoring of blood pressure, an essential measure of health status,

range of human blood pressures. This formula is validated by literature data as

Conflict of interest statement: The authors declare no conflict of interest.

3. Stud Health Technol Inform. 2018;249:77-83.

Gholamhosseini H(1), Baig M(1), Rastegar S(1), Lindén M(2).

BP measurement techniques. Currently, PPT-based BP measurement approaches have

such as that used in auscultatory and oscillometric BP measurement techniques.

the true representation of BP changes. This paper presents a continuous and

PMID: 29866960 [Indexed for MEDLINE]

El Hajj C, Kyriacou PA.

5. IEEE Trans Biomed Eng. 2019 Apr;66(4):967-976. doi:

Huynh TH, Jafari R, Chung WY.

OBJECTIVE: To demonstrate the feasibility of everaging impedance plethysmography

6. Physiol Meas. 2019 Jul 23;40(7):075001. doi: 10.1088/1361-6579/ab1f17.

Noninvasive cuffless blood pressure estimation using pulse transit time,

Thambiraj G(1), Gandhi U, Devanand V, Mangalanathan U.

OBJECTIVE: Continuous cuffless blood pressure (BP) monitoring research has

BP monitoring in clinical settings. However, the non-Newtonian fluid nature of

Cuffless Blood Pressure Estimation from only the Waveform of

Shimazaki S, Kawanaka H, Ishikawa H, Inoue K, Oguri K.

pressure estimation from only PPG by using CNN is examined.

8. Sci Rep. 2018 May 8;8(1):7298. doi: 10.1038/s41598-018-25681-5.

Cuffless blood pressure estimation using only a smartphone.

Matsumura K(1)(2)(3), Rolfe P(4)(5), Toda S(6), Yamakoshi T(7).

Science and Technology, Hokkaido University, Hokkaido, Japan.

Science and Technology, Hokkaido University, Hokkaido, Japan.

Cuffless blood pressure (BP) measurement is an all-inclusive term for a method

the knowledge that ln BP = ln cardiac output (CO) + ln total peripheral

Conflict of interest statement: We have the following interests. The

patents, products in development or marketed products to declare.

9. Physiol Meas. 2018 Feb 26;39(2):025005. doi: 10.1088/1361-6579/aaa454.

New photoplethysmogram indicators for improving cuffless and continuous blood

OBJECTIVE: The accuracy of cuffless and continuous blood pressure (BP)

10. Sensors (Basel). 2020 Sep 30;20(19):5606. doi: 10.3390/s20195606.

Real-Time Cuffless Continuous Blood Pressure Estimation Using Deep Learning

Li YH(1), Harfiya LN(1), Purwandari K(1), Lin YD(2).

Blood pressure monitoring is one avenue to monitor people's health conditions.

compare the performance between the traditional machine learning methods,

Conflict of interest statement: The authors declare no conflict of interest.

11. Hosp Pract (1995). 2019 Oct;47(4):211-215. doi:

The accuracy of blood pressure measurement by a smartwatch and a portable health

University, Philadelphia, PA, USA.

Objectives: Handheld medical devices and smartwatches that measure BP without a

The Everlast smartwatch provides measurements of systolic (SBP) and diastolic

of quiet sitting, four standard and three investigational BP measurements were

calculated by determining the average of the 2 standard BP measurements that

of variation in standard BP measurements per prespecified rules. Of 85

The Cuffless Blood Pressure Measurement with Multi-dimension Regression Model

According to the advancement of wearable technology, many physiological