The Handbook of Cuffless Blood Pressure Monitoring A

Practical Guide for Clinicians, Researchers, and Engineers

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Preface

Let us start with a typical scenario from clinical practice today.

During an annual physical exam:
143/97, Mr. Vailet, I have the feeling you are developing hypertension.
The day after, at Mr. Vailet’s home:
134/88
Two days after:
129/84
No further measurements until the day before the next physical exam, at Mr. Vailet’s
home:
148/95
Back to the physician’s office:
Mr. Vailet, where are the weekly blood pressure readings I asked you to do?
Measuring arterial blood pressure is a fundamental action when checking a
patient’s overall health. Nowadays, physicians and patients alike still rely on a
century-­old technology that requires the inflation of a cuff around the arm. This
leads to intermittent, sparse, or nonexistent monitoring of a patient’s health status
over long periods of time. As a result, millions of individuals are being wrongly
treated, underdiagnosed, or simply not diagnosed at all.
For more than a decade, an assembly of scientists, physicians, researchers, and
engineers have been working on the development and validation of novel technolo-
gies to overcome the burden of cuff-based blood pressure measurements. This book
is a tribute to this collective effort.
In 2017, we started crafting “The Handbook of Cuffless Blood Pressure
Monitoring: A Practical Guide for Clinicians, Researchers, and Engineers” that
you have now in your hands. From the beginning, we aimed at creating the first

v
vi Preface

comprehensive publication providing an overview of the emerging field of cuffless

blood pressure monitoring. We gathered the most knowledgeable authors around the
world who could summarize the basics, the medical context, the potential, and the
technical challenges of cuffless blood pressure monitoring. This work is now done.
Dear reader, if you are a researcher, clinician, engineer, journalist, investor, or
student who wants to get into the field of cuffless blood pressure, we are convinced
you will enjoy diving into these chapters.

Neuchâtel, Switzerland  Josep Solà

  Ricard Delgado-Gonzalo
Acronyms

AAMI Association for the Advancement of Medical Instrumentation

ABPM Ambulatory blood pressure monitoring
AI/AIx Augmentation index
ANSI American National Standards Institute
AP Augmented pressure
APG Acceleration plethysmogram
BCG Ballistocardiography
BHS British Hypertension Society
BP Blood pressure
CT Computed tomography
DBP/DIA Diastolic blood pressure
DIA Diastolic blood pressure
DL Deep learning
DNN Deep neural network
DPTI Diastolic pressure-time index
DT Diastolic time
ECG Electrocardiography
EHS European Home Systems
EMAT Electromechanical activation time
ESH European Society of Hypertension
ESP End-systolic pressure
FDA Food and Drug Administration
FF Form factor
FQP Four-quadrant plot
GCP Good clinical practice
GTF Generalized transfer function
HR Heart rate
ICG Impedance cardiography
IDE Investigational device exemption
IEEE Institute of Electrical and Electronics Engineers
IPG Impedance plethysmography

vii
viii Acronyms

IR Infrared
ISO International Organization for Standardization
IVCT Isovolumic contraction time
LED Light-emitting diode
LSTM Long short-term memory
LVET Left ventricular ejection time
MAD Mean absolute differences
MAP Mean arterial pressure
MAPD Mean absolute percentage difference
MDBP Mean diastolic blood pressure
ML Machine learning
MSBP Mean systolic blood pressure
NIBP Noninvasive blood pressure
NN Neural network
NPMA N-point moving average
PAT Pulse arrival time
PCG Phonocardiography
PDA Pulse decomposition analysis
PEP Pre-ejection period
PMA Premarket approval
PP Pulse pressure
PPG Photoplethysmography
PTT Pulse transit time
PWA Pulse wave analysis
PWD Pulse wave decomposition
PWTT Pulse wave transit time
PWV Pulse wave velocity
RI Reflection index
RMSE Root mean square error
RNN Recurrent neural network
SBP Systolic blood pressure
SCG Seismocardiography
SD Standard deviation
SEVR Subendocardial viability ratio
SI Stiffness index
SPTI Systolic pressure-time index
SVM Support vector machine
SVR Support vector regression
SYS Systolic blood pressure
Contents

  1 Cuffless Blood Pressure Monitoring and the Advent of a

New Era in Medicine and Society����������������������������������������������������������    1
Alberto Avolio, Fatemeh Shirbani, Isabella Tan, and Mark Butlin
  2 Clinical Relevance of Continuous and Cuffless
Blood Pressure Monitoring ��������������������������������������������������������������������    9
Gianfranco Parati
  3 A Historical Journey on the Physiology of Blood
Pressure Monitoring��������������������������������������������������������������������������������   15
Audrey Adji and Michael F. O’Rourke
  4 The Definition and Architecture of Cuffless Blood
Pressure Monitors������������������������������������������������������������������������������������   31
Josep Solà
  5 Pulse Arrival Time Techniques ��������������������������������������������������������������   43
Marshal S. Dhillon and Matthew J. Banet
  6 Pulse Wave Velocity Techniques��������������������������������������������������������������   61
Jim Li
  7 Pulse Decomposition Analysis Techniques��������������������������������������������   75
Martin C. Baruch
  8 Pulse Wave Analysis Techniques������������������������������������������������������������ 107
Martin Proença, Philippe Renevey, Fabian Braun, Guillaume Bonnier,
Ricard Delgado-­Gonzalo, Alia Lemkaddem, Christophe Verjus,
Damien Ferrario, and Mathieu Lemay
  9 Machine Learning Techniques���������������������������������������������������������������� 139
Xiaorong Ding

ix
x Contents

10 Initialization of Pulse Transit Time-Based Blood

Pressure Monitors������������������������������������������������������������������������������������ 163
Ramakrishna Mukkamala and Jin-Oh Hahn
11 Key Regulatory Aspects and the Importance of
Consensus Standards in Bringing Devices to Market�������������������������� 191
Carole C. Carey
12 Design of Clinical Trials to Validate Cuffless
Blood Pressure Monitors ������������������������������������������������������������������������ 203
Willem J. Verberk
13 Cuffless Blood Pressure Monitoring: The Future
for the Evaluation and Management of Hypertension ������������������������ 225
George S. Stergiou

Index������������������������������������������������������������������������������������������������������������������ 231
Contributors

Audrey Adji St Vincent’s Clinical School, University of New South Wales, Sydney,
NSW, Australia
Department of Biomedical Sciences, Faculty of Medicine and Health Sciences,
Macquarie University, Sydney, NSW, Australia
Alberto Avolio Department of Biomedical Sciences, Faculty of Medicine and
Health Sciences, Macquarie University, Sydney, NSW, Australia
Matthew J. Banet toSense, Inc., San Diego, CA, USA
Martin C. Baruch Caretaker Medical LLC, Charlottesville, VA, USA
Guillaume Bonnier Swiss Center for Electronics and Microtechnology (CSEM,
Centre Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland
Fabian Braun Swiss Center for Electronics and Microtechnology (CSEM, Centre
Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland
Mark Butlin Department of Biomedical Sciences, Faculty of Medicine and Health
Sciences, Macquarie University, Sydney, NSW, Australia
Carole C. Carey C3-Carey Consultants, LLC, Fulton, MD, USA
Ricard Delgado-Gonzalo Swiss Center for Electronics and Microtechnology
(CSEM, Centre Suisse d’Electronique et de Microtechnique), Neuchâtel,
Switzerland
Marshal S. Dhillon toSense, Inc., San Diego, CA, USA
Xiaorong Ding Institute of Biomedical Engineering, Department of Engineering
Science, University of Oxford, Oxford, UK
Damien Ferrario Swiss Center for Electronics and Microtechnology (CSEM,
Centre Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland

xi
xii Contributors

Jin-Oh Hahn Department of Mechanical Engineering, University of Maryland,

College Park, MD, USA
Mathieu Lemay Swiss Center for Electronics and Microtechnology (CSEM,
Centre Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland
Alia Lemkaddem Swiss Center for Electronics and Microtechnology (CSEM,
Centre Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland
Jim Li Global Medical Affairs, Omron Healthcare, Inc., Lake Forest, IL, USA
Ramakrishna Mukkamala Department of Electrical and Computer Engineering,
Michigan State University, East Lansing, MI, USA
Michael F. O’Rourke St Vincent’s Clinical School, University of New South
Wales, Sydney, NSW, Australia
Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
Gianfranco Parati Department of Medicine and Surgery, University of Milano-­
Bicocca, Milan, Italy
Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico
Italiano, IRCCS, San Luca Hospital, Milan, Italy
Martin Proença Swiss Center for Electronics and Microtechnology (CSEM,
Centre Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland
Philippe Renevey Swiss Center for Electronics and Microtechnology (CSEM,
Centre Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland
Fatemeh Shirbani Department of Biomedical Sciences, Faculty of Medicine and
Health Sciences, Macquarie University, Sydney, NSW, Australia
Josep Solà Aktiia SA, Neuchâtel, Switzerland
George S. Stergiou Hypertension Center STRIDE-7, National and Kapodistrian
University of Athens, Third Department of Medicine, Athens, Greece
Isabella Tan Department of Biomedical Sciences, Faculty of Medicine and Health
Sciences, Macquarie University, Sydney, NSW, Australia
Willem J. Verberk Microlife AG, Widnau, Switzerland
CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht,
The Netherlands
Christophe Verjus Swiss Center for Electronics and Microtechnology (CSEM,
Centre Suisse d’Electronique et de Microtechnique), Neuchâtel, Switzerland
Chapter 1
Cuffless Blood Pressure Monitoring
and the Advent of a New Era in Medicine
and Society

Alberto Avolio, Fatemeh Shirbani, Isabella Tan, and Mark Butlin

Abstract Measurement of arterial blood pressure (BP) by the brachial cuff sphyg-
momanometer has been a cornerstone of modern medicine, and notwithstanding its
limitations of intermittent BP monitoring, the cuff sphygmomanometer has not been
surpassed by any other noninvasive methodology. However, advances in sensor
technology for arterial pulse detection have paved the way for the potential develop-
ment of devices for cuffless measurement of BP, with the prospect of continuous
monitoring. Just as the cuff sphygmomanometer could be considered as having pro-
vided a significant step in establishing elevated BP as a major factor of cardiovascu-
lar risk since the turn of the twentieth century, cuffless BP monitoring might be
considered a disruptive technology for continuous BP monitoring in healthy indi-
viduals during daily living and could become an integral component of modern
digital health platforms in the twenty-first century. This volume of the Handbook of
Cuffless Blood Pressure Monitoring addresses the significant challenges faced by
this methodology. The underlying physiology and hemodynamic principles involved
in the generation of the arterial pressure pulse are complemented by the clinical
relevance of the novel cuffless methodologies in relation to the conventional cuff
sphygmomanometer. The underlying pressure dependency of arterial properties,
which is at the base of the cuffless technique employing pulse transit measurement
as a surrogate measure of BP, is addressed in association with instrumentation, mea-
surement techniques, calibration procedures, device validation and regulatory
requirements. This book provides a timely and comprehensive platform on how to
approach the critical question of whether cuffless is the future of BP monitoring.

Keywords Arterial stiffness · Pulse wave velocity · Pulse transit time ·

Sphygmomanometer · Blood pressure · Cuffless techniques · Peripheral pulse ·
Arterial hemodynamics · Big data

A. Avolio (*) · F. Shirbani · I. Tan · M. Butlin

Department of Biomedical Sciences, Faculty of Medicine and Health Sciences,
Macquarie University, Sydney, NSW, Australia
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 1

J. Solà, R. Delgado-Gonzalo (eds.), The Handbook of Cuffless Blood Pressure
Monitoring, https://doi.org/10.1007/978-3-030-24701-0_1
2 A. Avolio et al.

Introduction

There is a notable coincidence between the accepted dates marking the publication
of the first clinical use of the cuff sphygmomanometer by Scipione Riva-Rocci
(15 December 1896) in Turin, Italy and the first projection of cinema to a paying
audience by brothers Auguste and Louis Lumière (28 December 1895) in Paris,
France. In addition to the remarkable proximity of the official dates, only 1 year
apart, the two milestone events have a common origin through the work of French
physiologist Étiene-Jules Marey in his studies of the circulation of blood. His evolv-
ing attempts to obtain quantitative representation of the force of the arterial pulse as
detected and registered by graphic means paved the way for the invention of the
sphygmograph, This led to the construction of devices for achieving time-lapsed
photography to capture movement, culminating in series of ground-breaking publi-
cations and in the coining of the term chronophotography, a technique used to study
movement in flight [1] and which influenced the seminal flight experiment of the
Wright brothers in 1903 at Kitty Hawk, marking the birth of modern aviation.
Although the arterial pulse has been used in medical diagnoses and described
qualitatively since antiquity, the use of the sphygmograph enabled the first ever
quantitative registration of any physiological parameter—a cuffless measure of arte-
rial pressure, and long before the registration of the electrocardiogram. It was the
efforts of many scientists and inventors such as Marey in the search for mechanical
devices capable of producing an image of the varying morphology of the arterial
pulse, coupled with advances in photography, that enabled the evolution and conver-
gence of sphygmography and chronophotography. The one resulting in the advent
and clinical use of the cuff sphygmomanometer by the Italian physician Riva-Rocci
and the other in the promotion of cinema by French scientists and entrepreneurs
such as the Lumière brothers in the late nineteenth century. With the dawn of the
twentieth century, technological advances in the form of the cuff sphygmomanom-
eter and cinema produced respective fundamental changes in the way medicine was
practiced and in the way the moving image was used for enhanced communication
and enrichment of the human experience. Both have had an immeasurable impact
on human health and culture in society.

 uffless Monitoring of Blood Pressure: A Disruptive Step

C
in Health Management

The above advances were not made in isolation, but were integral component parts
of a movement of progressive development of ideas and concepts that revolution-
ized scientific thinking and technological applications in the eighteenth and nine-
teenth centuries. History is rich with iconic milestones such as James Watt’s
development of the steam engine (cc 1780s) that was a major driving force for the
industrial revolution. Perhaps one of the most significant fundamental unifying
1 Cuffless Blood Pressure Monitoring and the Advent of a New Era in Medicine… 3

concepts in human history, the description of electromagnetic radiation by James

Maxwell in 1865, has extended the application of human endeavor beyond the
Newtonian view of the world to Einstein’s concepts of relativity and to quantum
mechanics. In modern parlance, and given the significant impact these develop-
ments have made on society as a whole, they might be described as highly “disrup-
tive” in comparison to what came before.
And it is precisely the notion of “disruption” that is at the center of the transition
from blood pressure being measured intermittently as a clinical parameter by the
cuff sphygmomanometer to blood pressure being monitored continuously by cuff-
less devices. Just as the intellectual and scientific pathways that led to the develop-
ment of the cuff sphygmomanometer were intertwined with advances and pitfalls in
other avenues of scientific and technological endeavor in the nineteenth century, the
development of cuffless blood pressure technology will tread similar ground in the
twenty-first century. The difference being that the disruptive elements in the cuffless
journey are supported and boosted by the immense power of all that is digital—the
Internet, global positioning systems, satellite communication, cloud computing,
miniaturization of computer chips and electronic circuits, intelligent algorithms,
developments in sensor technology supported by intelligent materials. The differ-
ence will also extend to the use of the devices. Whereas the cuff sphygmomanom-
eter, virtually unchanged since its inception, has been essentially used for detection
of markers associated with pathology (hypertension), cuffless monitoring of blood
pressure will be incorporated in wearable devices, thus enabling collection of data
in normal daily living of individuals in society, in the form of “big data.” It is yet not
known in what way this form of data collection will modify the practice of medicine
and how it will affect the understanding of blood pressure profiles with daily habits
or lead to phenotypic classifications of normal individuals in the context of genetic
analysis and precision medicine. However, there is a precedent. When brachial cuff
blood pressure values were systematically collected using pen and paper by life
insurance companies in the early twentieth century [2], it led to the understanding
of how asymptomatic high blood pressure can be one of the most powerful factors
of cardiovascular risk.

Underlying Principles of Cuffless Methodology

An important overarching concept underlying cuffless measurement of blood pres-

sure is the fundamental relationship between transmural pressure and mechanical
properties of the arterial wall which influence wave propagation phenomena [3].
This is the pressure dependency of the material stiffness of all blood vessels. This
property is present in all species with pressurized circulatory systems and is a fun-
damental evolutionary property of arterial design [4]. Since, in any physical system,
wave propagation is determined by the bulk modulus of the material, the speed of
any disturbance (due to cardiac contraction and ejection) that travels along the arte-
rial wall is directly related to vessel stiffness. And given the essential relationship of
4 A. Avolio et al.

arterial stiffness and distending pressure, any measure of the velocity of the travel-
ling pulse wave would be a measure of arterial pressure. This is an important con-
sideration because pulse wave velocity (PWV) is directly related to blood pressure
and so an accurate measurement of PWV should theoretically deliver a measure of
blood pressure, provided that the relationship of PWV and blood pressure of the
specific arterial path length is known. Changes in blood pressure would then be
registered as changes in PWV, or more specifically, for a fixed distance, as changes
in pulse transit time (PTT) [3]. Hence, on theoretical considerations, cuffless mea-
surement of blood pressure using PTT could be considered to be a more robust
measure of intra-arterial pressure than that obtained by using indirect surrogate sig-
nals such as appearance of a distal pulse (palpatory method), Korotkoff sounds (aus-
cultatory method) or features of the envelope of the oscillation of cuff pressure
during cuff deflation (oscillometric method).

The Handbook of Cuffless Blood Pressure Monitoring

This volume of The Handbook of Cuffless Blood Pressure Monitoring, the first of its
kind, promises to be a guide in the modern twenty-first century journey of novel
developments of methods and technology for monitoring of blood pressure, meth-
odologies and techniques which go beyond the traditional cuff sphygmomanometer.
It is a timely endeavor, and its publication will be an important milestone in this new
field. It is both important and essential. Wearable, mainly wrist-worn devices are
being produced that purport to measure blood pressure. Being connected to the
Internet, they transmit data to databanks that log blood pressure values for individu-
als during daily activities. Being consumer devices, there is generally little or no
regulatory requirement for the blood pressure measurement, other than device
safety. With increasing use of these devices, it is conceivable that blood pressure
data will be mined from big data sources and potentially “useful” knowledge will be
extrapolated. However, there is no guarantee that the information from such data has
any reliable relation to continuous blood pressure or any potential physiological
significance. This is because of the inherent complexity in translating the noninva-
sive cuffless surrogate signal to a physiological arterial pressure. That is, the reli-
ability of the basic methodology of calibration [5, 6]. This is in contrast to the cuff
sphygmomanometer, where the cuff pressure is actually measured with high preci-
sion, and specific levels of cuff pressure are associated with arterial phenomena,
such as appearance and disappearance of Korotkoff sounds associated with systolic
and diastolic pressure, although to a varying degree of association and correlation.
The chapters in this book are comprehensive and cover a wide range of topics, all
of which are highly relevant to the scientific, technological, industrial, and clinical
aspects of the field of cuffless and continuous measurement of arterial blood pres-
sure. The material presented in all the chapters offers a robust platform on which to
launch this new field and which builds on the large amount of published work based
on basic concepts of the circulation involved in the genesis of the pressure pulse,
1 Cuffless Blood Pressure Monitoring and the Advent of a New Era in Medicine… 5

sensor technology, device development and fabrication, signal processing, deep

learning strategies, modelling, calibration procedures, in vivo, in vitro, and in silico
experimentation, and methods of validation.
This book addresses critical aspects relevant to the monitoring of blood pressure
using cuffless techniques in 12 chapters. The following 11 chapters can be divided
into three broad topic sections:
Topic Section 1 (Chaps. 2 and 3) describes the underlying physiology and hemo-
dynamic principles involved in the generation of the arterial pressure pulse and the
clinical relevance of the novel cuffless methodologies in relation to the conventional
cuff sphygmomanometer. The important distinction between the new and old tech-
niques for blood pressure monitoring is that the cuff sphygmomanometer is usually
associated with the detection, treatment and management of hypertension, thus a
pathological condition. Novel, cuffless techniques, embedded in wearable devices,
will be associated with monitoring continuous changes in blood pressure predomi-
nantly in normal individuals during daily activities. This will undoubtedly have an
impact on the meaning of such things as blood pressure thresholds that separate the
“normal” state from the “pathological” state. This suggests significant “disruption”
in the actual understanding of what constitutes “hypertension” in association with a
plethora of other health data obtained by wearable devices and interpreted by data
analytics.
Topic Section 2 (Chaps. 4–9) describes the areas of cuffless devices involving
instrument components, measurement techniques and calibration procedures. This
Topic Section is critical to the fundamental understanding of the essential compo-
nents of what constitutes a cuffless device for monitoring of arterial blood pressure.
The basic requirement is the detection of the arterial pulse, with sensor modality
being key for reliable pulse detection. An important distinction between sensors
used for cuffless devices is that they do not necessity need to provide a quantitative
measure of the force of the arterial pulse, but rather a fiducial signal which is in
synchrony with the beating heart. The measurement of arterial pressure is based in
temporal characteristics, so there is no requirement for absolute grading of mea-
sured signals. This enhances the capacity of available sensors for signal detection
and the scope for instrumentation to be adapted to wearable devices. However,
while sensors may be sufficiently robust for signal detection, the conversion of a
measured time delay (irrespective of the degree of accuracy) to a physiologically
relevant blood pressure remains one of the most challenging aspects of this field. To
date, calibration issues remain unresolved, particularly in terms of stability, fre-
quency of performing calibrations, procedures involved in obtaining adequate
ranges of blood pressure and the differences in relationships between pulse transit
time and arterial pressure for different arterial sites, or even at different levels of
blood pressure. The limitations related to inconsistent physiological relationships
can be addressed using data-driven procedures involving machine learning tech-
niques [7]. However, it is not yet known how different databases can be sufficiently
regulated to produce reliable training platforms for a broad range of algorithms
applied to machine learning approaches for blood pressure monitoring.
6 A. Avolio et al.

Topic Section 3 (Chaps. 10–12) addresses the important area of device validation
in the context of regulatory requirements and standards. To a certain extent, there is
a conceptual overlap between “cuffless” and “continuous” techniques for blood
pressure monitoring which is not adequately addressed by the current standards.
Hence, there is a need for clear and definite guidance for evaluation from regulatory
authorities so as to provide sufficient certainty for the medical devices industry.
Finally, with appropriate validation, future projections are made on the expectations
of the use of cuffless devices for diagnosis and management of hypertension.
However, this will need to be in the context of the potential disruption to the concept
of hypertension and blood pressure thresholds.
All chapters are comprehensive and authoritative. They cover a broad range of
relevant topics that enable and enhance understanding of the field of cuffless blood
pressure monitoring at a considerable depth. While there will be some necessary
and unavoidable repetition of some sections in different chapters, this is a positive
aspect as it highlights their relative importance and contributes to placing this new
field in the historical, technological and social continuum.

Is “Cuffless” the Future of Blood Pressure Monitoring?

The comprehensive nature of this volume brings out the advances as well as the
formidable challenges facing the journey of device development for reliable and
continuous monitoring of blood pressure using cuffless techniques. The “state of the
art” suggests that some milestones have already been achieved. Sensor technology
for pulse detection is highly evolved and robust. Advances in component miniatur-
ization and complex chip design have enabled the explosion of wearable devices
incorporating measurement and processing of physiological signals, providing
information on metrics that can guide decisions on health management. However,
while some of these metrics are highly reliable (e.g., heart rate, blood oxygen levels,
and many others) and have been available for some time, accurate, reliable continu-
ous, cuffless monitoring of blood pressure has presented insurmountable challenges.
There have been many patent submissions, start-up companies, and scientific pub-
lications, but to date there is no device that is universally accepted by the wider
community beyond research laboratories and company boardrooms.
This book will make a significant contribution to providing an informed answer
to this important question.

References

1. Marey E-J. Le vol des insectes étudié par la chronophotographie. La Nat. 1892;20(1):135–8.
2. Fischer JW. The diagnostic value of the sphygmomanometer in examinations for life insurance.
JAMA. 1914;63:3.
1 Cuffless Blood Pressure Monitoring and the Advent of a New Era in Medicine… 7

3. Mukkamala R, Hahn JO, Inan OT, Mestha LK, Kim CS, Töreyin H, Kyal S. Toward ubiquitous
blood pressure monitoring via pulse transit time: theory and practice. IEEE Trans Biomed Eng.
2015;62:1879–901.
4. Shadwick RE. Mechanical design in arteries. J Exp Biol. 1999;202:3305–13.
5. Butlin M, Shirbani F, Barin E, Tan I, Spronck B, Avolio AP. Cuffless estimation of blood
pressure: importance of variability in blood pressure dependence of arterial stiffness across
individuals and measurement sites. IEEE Trans Biomed Eng. 2018;65:2377–83.
6. Ding X, Zhang Y, Tsang HK. Impact of heart disease and calibration interval on accuracy of
pulse transit time-based blood pressure estimation. Physiol Meas. 2016;37:227–37.
7. Khalid SG, Zhang J, Chen F, Zheng D. Blood pressure estimation using photoplethysmog-
raphy only: comparison between different machine learning approaches. J Healthc Eng.
2018;2018:1548647.
Chapter 2
Clinical Relevance of Continuous
and Cuffless Blood Pressure Monitoring

Gianfranco Parati

Abstract The assessment of dynamic features of blood pressure, which represent a

response of cardiovascular control mechanisms to environmental stimulations and
to daily life challenges, not only offers important insights into cardiovascular regu-
lation patterns but also carries clinically relevant information. Availability of tools
for continuous blood pressure monitoring represents a key step to make such an
assessment possible, but its implementation in daily practice requires noninvasive,
simple and minimally intrusive methods. These methods are expected to overcome
the well-known limitations characterizing the conventional approach to blood pres-
sure measurement based on discontinuous blood pressure readings obtained through
repeated arm cuff inflations. In such a perspective, techniques able to provide con-
tinuous blood pressure monitoring without the need of a cuff inflation would be
welcome.

Keywords Continuous blood pressure monitoring · Blood pressure variability ·

Arm cuff inflation · Cuffless blood pressure measurement technology

Introduction

Blood pressure (BP) is one of the most dynamic physiologic variables among those
routinely measured in clinical practice, consisting of a series of pulse waves con-
tinuously changing in terms of both frequency and amplitude. BP is indeed charac-
terized by continuous and significant changes occurring over different time windows,
with beat-by-beat oscillations being intertwined in a complex manner with

G. Parati (*)
Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano,
IRCCS, San Luca Hospital, Milan, Italy
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 9

J. Solà, R. Delgado-Gonzalo (eds.), The Handbook of Cuffless Blood Pressure
Monitoring, https://doi.org/10.1007/978-3-030-24701-0_2