Change Point--Aware Evaluation and Re-Calibration of PPG-Based Blood Pressure Estimation

Continuous cuffless blood pressure (BP) monitoring is essential for connected health systems and wearable devices, enabling early detection, longitudinal tracking, and personalized management of cardiovascular disease. Many prior approaches attempt to estimate BP indirectly by reconstructing electrocardiography (ECG) from photoplethysmography (PPG), assuming ECG provides a stronger physiological link to BP. However, ECG sensing is less accessible in wearable settings and may introduce unnecessary complexity. In this work, we first perform a large-scale physiological correlation analysis on the MIMIC-III waveform database, revealing that PPG exhibits substantially stronger coupling with arterial blood pressure (ABP) ($|r|=0.247$, $p<0.001$) than ECG does ($r=0.018$, $p=0.187$), challenging the assumption that ECG provides a superior intermediate representation. Motivated by this insight, we conduct a systematic comparison between direct PPG-to-BP prediction and ECG-mediated pipelines using multiple state-of-the-art deep learning models. Across 1.74M segments from 3,127 patients, direct PPG-to-BP prediction achieves British Hypertension Society Grade A performance ($\mathrm{MAE}_{\mathrm{SBP}} = 4.82 mmHg$, $\mathrm{MAE}_{\mathrm{DBP}} = 4.31 mmHg$), outperforming all ECG-mediated approaches, which achieve only Grade B accuracy. Our findings suggest that accurate continuous BP monitoring can be achieved directly from wearable PPG signals, enabling simpler, more efficient pipelines for real-world connected health systems.

Continuous cuffless blood pressure (BP) monitoring from photoplethysmography (PPG) has strong potential for wearable health and telemonitoring, but accurate estimation remains difficult because PPG-to-BP mapping must preserve subtle waveform morphology and pressure-range-dependent dynamics. We introduce ExpertoRhythm, an attention-enhanced 1D U-Net that reconstructs the arterial blood pressure (ABP) waveform from a single-channel PPG signal and derives systolic and diastolic BP directly from the reconstructed waveform. The central contribution is a composite morphology-aware learning objective that integrates range-weighted SmoothL1 reconstruction with a window-range regularizer to emphasize high-dynamic BP segments and reduce amplitude under/over-shoot. On the UCI cuff-less BP dataset with 942 subjects, ExpertoRhythm achieves 2.46/1.46 mmHg MAE for systolic/diastolic BP (SBP/DBP), while obtaining a 30.4% average relative error reduction over pure MSE across waveform reconstruction and BP estimation metrics. Clinical-style evaluation further demonstrates low bias and strong agreement across the BP range, including high-pressure windows up to 200 mmHg, satisfying AAMI criteria and achieving BHS Grade A. These results suggest that morphology-aware waveform reconstruction from a single PPG channel can provide an accurate and practical pathway toward continuous cuffless BP monitoring in wearable and remote-care settings.

Continuous cuffless blood pressure (BP) monitoring remains challenging due to motion artifacts, physiological variability, and the limited robustness of conventional pulse transit time (PTT) models under dynamic conditions. Many prior approaches rely on multi-second windows to stabilize estimation, an assumption that is frequently violated during real-world monitoring with intermittent signal corruption. Here, we show that discriminative BP-related information is preserved at the single-beat level and present a lightweight multi-modal wearable framework for continuous BP estimation. The system integrates synchronized chest electrocardiography (ECG) and ear-clip reflectance photoplethysmography, each co-located with a 6-axis inertial measurement unit to provide motion context. We introduce a hybrid learning architecture in which a one-dimensional convolutional neural network extracts a 64-dimensional embedding from individual PPG beats and fuses it with 30 physiology-grounded features, including PTT statistics and heart rate variability, followed by LightGBM regression. The method was evaluated using a multi-phase stress protocol ($n=10$) and the PulseDB public dataset with subject-disjoint validation. Across 30 independent runs, the model achieved mean absolute errors of $4.02 \pm 0.21$~mmHg for systolic BP and $1.79 \pm 0.05$~mmHg for diastolic BP, corresponding to a 28.2% reduction in combined MAE relative to baseline models. By enabling beat-wise estimation without long temporal context, this framework supports computationally efficient cuffless BP monitoring suitable for wearable deployment under practical resource constraints. The source code for this work is available at https://github.com/SYMBIOX-Lab/BP-wireless.