ARTICLE IN PRESS

Engineering Applications of Artificial Intelligence 23 (2010) 968–977

Contents lists available at ScienceDirect

Engineering Applications of Artificial Intelligence

journal homepage: www.elsevier.com/locate/engappai

Heart rate extraction from photoplethysmogram on fuzzy logic discriminator

Shing-Hong Liu a,n, Kang-Ming Chang b, Tsu-Hsun Fu c
a
Department of Computer Science and Information Engineering, Chaoyang University of Technology, Taichung, Taiwan
b
Department of Photonics and Communication Engineering, Asia University, Taichung, Taiwan
c
Department of Biomedical Engineering, Yuanpei University, Hsinchu, Taiwan

a r t i c l e in f o a b s t r a c t

Article history: Photoplethysmography (PPG) is a noninvasive method suitable for extracting the HR when monitoring
Received 15 April 2009 the physiological condition. The PPG waveform is readily contaminated by various mechanisms, such as
Received in revised form raising or lowering the hand, breathing, changes in stroke volume, the presence of double dicrotic
21 December 2009
notches, and cardiovascular diseases. These made heart rate extraction a difficult problem. The purpose
Accepted 4 February 2010
of this study was to propose a heart rate extraction method that has better performance than the
Available online 11 March 2010
wavelet and correlation methods. A fuzzy logic discriminator was used to discriminate the truth of each
Keywords: peak of the slope of the PPG signal based on weights. A determining algorithm used these weights to
Photoplethysmogram extract the heart rate, and also to insert an interpolated peak near the time of a missing peak. This
Fuzzy logic discriminator
allowed the physiologic condition of a patient during the rapid heart rate change to be reliably
Heart rate
monitored. The study applied six different PPG waveforms to test our desired method. The root-mean-
Wavelet
Correlation square error values relative to the reference showed that the desired method for Case I is 5.15 beats/
min, and for Case IV (1) it is 0.
& 2010 Elsevier Ltd. All rights reserved.

1. Introduction resistance, (4) absence of the dicrotic notch or double dicrotic

Many studies have shown that the heart rate (HR) response
can be used to estimate heart function (Desai et al., 2001; Nishime
et al., 2000; Watanabe et al., 2001). The electrocardiograph or
continuous monitoring of the blood pressure is normally used to
measure the HR, but photoplethysmography (PPG) is an easier
method compared to them. The sensor of PPG is placed at the
finger whose weight is light and hence could be much easier to
wear. Some studies used it to develop a simple telemetry device
for monitoring pulse rate at a finger (Yamashita et al., 1995; Rhee
et al., 2001). These technologies could be applied to home care,
mental stress, or exercise physiology. Johansson et al. used the
PPG waveform to estimate the respiratory volumes (Johansson
and Oberg, 1999a, 1999b).
However, the stability of PPG signal is lower than the
electrocardiograph signal for HR extraction (Yu et al., 2006). The
following mechanisms can interfere with the PPG waveform: (1)
raising and lowering the hand to which the sensor is attached
results in the baseline changing with the local venous and arterial
hydrostatic pressure (Murray and Forster, 1996), (2) the change in
intrathoracic pressure during the respiratory cycle displaces the
baseline and changes its amplitude (Johansson and Oberg, 1999a,
1999b), (3) changes in amplitude result from the interaction of
the left ventricular stroke volume and peripheral vascular
n
Corresponding author. Tel.: + 886 4 23323000.
E-mail address: shliu@cyut.edu.tw (S.-H. Liu).
notches can be induced by valve closure or a hyperdynamic artery
to its venae comitans (Murrary and Gorven, 1991; O’Rourke and
Yaginuma, 1984), and (5) the waveform is affected by cardiovas-
cular diseases. It is not possible to obtain a precise and stable HR
when the amplitude of the PPG waveform is too low or in the
presence of baseline fluctuations due to the above factors. Such
missing beats also can cause sudden apparent HR changes and
lead to false parameters of HR response.
Various methods have been proposed for removing motion
artifacts from PPG waveforms: Kim et al. combined an inherently
quasi-periodic method and independent component analysis
(Kim and Yoo, 2006), while Hayes et al. created a model to
describe the motion artifact as a linear factor modulating the
coupling of light from both static and pulsatile tissues (Hayes and
Smith, 2001). These methods focused on how to compensate for
the contaminated signals and allow the HR to be extracted easily.
There are also methods for extracting the beat-to-beat interval
(BBI) from the blood pressure signal or PPG signal, such as slope,
correlation, and wavelet detection (Nakajima et al., 1996;
Suhrbier et al., 2006; Fu et al., 2008). These are preprocessing
methods that enhance the characteristics of the waveform or
smoothen the waveform into a sine wave. Then, a sufficiently high
difference value, such as a threshold trigger, or a local maximum
detection is used as the index for BBI extraction.
However, it remains challenging to measure the BBI from a
raw PPG signal that is contaminated by breathing, large changes
in the PPG waveform baseline, double dicrotic notches, or
cardiovascular diseases. Fuzzy logic has recently been widely

0952-1976/$ - see front matter & 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.engappai.2010.02.008
 ARTICLE IN PRESS
S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977
applied to analyze biomedical control and feature extraction (Lin
et al., 2003; Huang et al., 1999; Lin and Lee, 1996). One of the
advantages of fuzzy logic is that it can be applied empirically
without explicit mathematical models of the underlying nonlinear
physiological systems. Also, it is easy to implement a feature
extraction system using fuzzy logic since this is based on
linguistic rules. In this paper, we propose an HR detection method
that includes a slope calculation, a fuzzy logic discriminator (FLD),
and an algorithm for determining the peak index. The use of the
differential waveform allows the drift in the baseline PPG signal to
be removed and enhances the change in the perfusion duration of
PPG. The FLD was used to evaluate the truthfulness of each peak
as a weight. The determining algorithm used the weight of a peak
to detect the index of maximum slope and adjusted the input
parameters of the FLD for the next peak. The capability of our
proposed HR detection method was tested using the following six
examples of contamination: raising and lowering the hand,
respiration disturbance, changes in amplitude, presence of no
dicrotic notch or of double dicrotic notches, and premature atrial
contraction (PAC). To evaluate the performance we also used
wavelet multiresolution analysis and a correlation detection
method to extract the HR for these six different examples.
This paper is organized as follows. Section 2 describes the
design of the FLD parameters, the flow diagram of the determin-
ing algorithm, the correlation method, and the wavelet method.
The six different cases for the PPG waveform also are detailed in
this section. Section 3 compares the performance of the FLD
method with those of the correlation and wavelet methods, and
presents the recorded HR responses. The results are discussed and
conclusions are drawn in Section 4.
2. Materials and methods
Fig. 1 shows a block diagram of the proposed measurement
system. The entire system includes a specific simple pulse
oximeter (SpO2) monitor, a differentiator, parameter calculation,
an FLD, a determining algorithm, and a peak detector. The SpO2
monitor used (SA200, Rossmax, Taiwan) a sampling rate of 250 Hz
outputted PPG digital signals corresponding to red and infrared
light intensities via a serial port to the computer. The PPG signal
of the SpO2 monitor is preprocessed by a differential equation to
evaluate the slope signal and remove the baseline drift of the PPG
signal and enhance the change in the perfusion duration of PPG.
The disturbance characteristics of Pre_Ratio, Pos_Ratio, and y
(defined in Section 2.1.1) are then extracted from the slope
signal. The FLD uses these parameters to evaluate a weight
representing the truthfulness of the peak of the slope signal, and a
determining algorithm uses this weight to detect the actual peaks
of the perfusion cycle and adjust Pre_PP, Pos_PP, and N_PP (defined
in Section 2.1.1). Based on the determining algorithm, the peak
SpO2 Monitor
PPG
Differential S Calculating
Equation Parameters
Pre_PP
Pos_PP
N_PP[n+1]
Fig. 1. Block diagram of the proposed measurement system. The system includes a specific SpO2 monitor, an injector trigger, a differentiator, parameter calculations, an
FLD, a determining algorithm, and peak detection.
969
detector determines the perfusion peak of the raw PPG waveform
by identifying the maximum value of the PPG waveform following
the actual peak of the slope signal. The HR of beat-to-beat is
calculated.
In this section, we also present the other two extraction
methods (correlation and wavelet) that were used to smoothen
the PPG waveform into a sine wave. Detection of the local
maximum was used to identify the peak index. A gold standard
BBI was manually extracted from the PPG signal.
2.1. Fuzzy logic discriminator for peak determination
The PPG waveform has a maximum slope when the left
ventricle pumps into the aorta. For computational efficiency, the
slope Di at point i was calculated as the average of three data-
point differences di1, di2, and di3 within a window of size m. The
stroke cycle of the left ventricle is about 0.1 s, and hence we used
m= 40 for the sampling rate of 250 Hz. The transfer function is
defined as follows:
1 
HðzÞ ¼ ð1zm Þ þðz1 zðm þ 1Þ Þ þ ðz2 zðm þ 2Þ Þ : ð1Þ
3
The slope signal is very sensitive to changes in the PPG
waveform, and contains more peaks than the raw PPG signal. In
the general method, a threshold is normally used to determine a
local maximum. However, the peak is larger for a larger PPG
waveform, and so a fixed threshold is insufficient for detecting the
maximum of the slope signal, making it necessary to design an
efficient algorithm for determining the local maximum.
2.1.1. The normal PPG waveform and characteristics
Fig. 2 shows a standard PPG signal and its slope, which exhibits
only one perfusion peak and one dicrotic notch peak. The slope
signal can sensitively represent the change in the PPG waveform
with a reduced baseline offset, as shown in Fig. 2(b). The
maximum peak of the slope signal occurs at the perfusion cycle
of the PPG waveform. Thus, we defined it as the actual peak of the
perfusion cycle. In order to detect these actual peaks, we defined
some parameters for the slope signal. I[n] represents the interval
between any two contiguous peaks of the slope signal, and Pre_PP
is defined as the interval between the two actual peaks of the
perfusion cycle. We first define any detected peak of the slope
signal, P2, as being the actual peak of perfusion cycle. Thus, Pre_PP
of P2 is
Pre _PP ¼ I½n1; ð2Þ
when P1 is an actual peak of the perfusion cycle. When P2 is found
to not be a peak of the perfusion cycle, Pre_PP of P3 will be
Pre _PP ¼ Pre _PP þ I½n: ð3Þ
Peak HR
Detector
Pre_Ratio
Pos_Ratio FLD W Determining
Algorithm
θ
 ARTICLE IN PRESS
970 S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977

Fig. 2. (a) A standard PPG waveform only has one perfusion peak and one dicrotic notch and (b) definition of parameters in the slope signal.

Pos_PP is defined as the interval between the current peak and (4) the presence of no dicrotic notch or of double dicrotic notches
the next peak of the slope signal: due to valve closure or a hyperdynamic artery to its venae
Pos _PP ¼ I½n þ1: ð4Þ comitans, and (5) other changes in the PPG waveform due to
cardiovascular diseases. Baseline data of the six patients are
PP (defined in Section 2.1.4) is the actual peak-to-peak interval presented in Table 1.
for two contiguous perfusion cycles of the PPG waveform. A Case I: The baseline PPG waveform is stable in a resting
normalized parameter, N_PP, is recursively adjusted using both condition. However, the baseline PPG waveform changes when
the normalized parameter and the PP: raising and lowering the hand due to alterations in the venous
N_PP½n þ1 ¼ 0:8N_PP½n þ0:2PP; ð5Þ hydrostatic pressure of the local tissue. Fig. 3(a) shows a typical
PPG waveform with a varying baseline.
when the actual peak of the perfusion cycle of the PPG waveform
Case II: The changes in the intrathoracic pressure during the
is determined by the FLD. The ratio of Pre_PP and N_PP (Pre_Ratio)
respiratory cycle also displace the baseline and change the
and the ratio of Pre_PP and N_PP (Pre_Ratio) are defined as
  amplitude of the PPG waveform. During normal spontaneous
Pre _PP breathing, the PPG signal appears as a slow phasic respiratory
Pre _Ratio ¼ Abs 1 ; ð6Þ
N_PP wave that shapes the envelope of the cardiac pulsations. Fig. 3(b)
  shows the respiratory trace in the envelope of the PPG waveform,
Pos _PP and a transient corresponding to the changes in venous hydro-
Pos _Ratio ¼ Abs 1 : ð7Þ
N_PP static pressure. The amplitude of the PPG waveform is also
The angle (y) formed between one specific P3 and its two modulated by positive pressure ventilation.
contiguous peaks of the notch cycle, P2 and P4, is given by Case III: The PPG waveform reflects tissue perfusion in the
y = +P2P3P4 in Fig. 2(b). We observed that y is acute when the finger due to interaction of the left ventricular stroke volume and
specific peak, P3, is an actual peak of the perfusion cycle, and peripheral vascular resistance. Therefore, the amplitude will
obtuse between the peak of the notch cycle, P4, and its two change with a change in the blood flow or in the elasticity of
contiguous peaks of the perfusion cycle, P3 and P5 (i.e., the local tissue artery. Changes (including in the amplitude) are
y’ =+P3P4P5). also possible due to the SpO2 meter adjusting the power delivered

2.1.2. The interfered PPG waveform Table 1

The peripheral pulse wave is generated by blood ejected from Baseline patient data for the five cases.
the heart during the opening of the aortic valve. The waveform is
shaped by this pressure interacting with complex elastic and Case Case Case III Case IV Case IV Case V
I II (1) (2)
resistive elements in the vascular tree. In this study, we selected
the following five typical changes in PPG waveforms: (1) changes Gender Male Male Female Male Female Female
in the baseline PPG waveform due to raising and lowering the Age (yr) 33 24 20 49 39 45
hand, (2) modulation of the baseline and amplitude of the PPG Resting HR (beats/ 93 74 75 102 58 71
waveform by positive pressure ventilation, (3) changes in min)
SBP (mm Hg) 134 118 114 145 102 98
amplitude resulting from changes in the left ventricular stroke DBP(mm Hg) 86 71 61 95 53 62
volume or in the power of the photodiode of the pulse oximeter,
 ARTICLE IN PRESS
S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977 971

Fig. 3. The five typical PPG waveforms: (a) changes in the baseline PPG waveform due to raising and lowering the hand, (b) modulation of the baseline and amplitude of the
PPG waveform by the respiration rate and volume, (c) changes in amplitude resulting from changes in the left ventricular stroke volume or in the power of the photodiode
of the pulse oximeter, (d) absence of the dicrotic notch, (e) presence of double dicrotic notches, and (f) the PPG waveform in the presence of a PAC.
 ARTICLE IN PRESS
972 S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977

by the photodiode to balance the ratio of the red light and infrared interval of the contiguous peaks lies within the normal HR range.
light when it calculates the percentage of the oxygen saturation in We also observe that angle y between the peak of the perfusion
the blood. In Fig. 3(c) the amplitude of the PPG waveform is cycle, P3, and its two contiguous peaks of the notch cycle, P2 and
smaller at the end of the ventricular diastole. P4 (i.e., y =+P2P3P4 in Fig. 2(b)), is acute. However, if the PPG
Case IV: The dicrotic notch is classically attributed to closure of waveform does not have a dicrotic notch or has double dicrotic
the aortic valve at the end of the ventricular systole. The vertical notches, as shown in Fig. 4(d) and (e), the angle between the
position of the notch on the waveform has been used as an contiguous peaks of the perfusion cycle is not consistent with the
indicator of vasomotor tone. Diseases of the myocardium or aortic above descriptions. Fig. 4 shows the slope of the PPG signals for
valve can result in the dicrotic notch disappearing from the PPG case VI. The angle y = +P1P2P3 will be close to 180o when the PPG
waveform, as shown in Fig. 3(d). The presence of double dicrotic waveform does not have the dicrotic notch, as shown in Fig. 4(a).
notches is due to strong pressure waves being reflected back via However, Fig. 4(b) shows that the angle y0 =+P10 P20 P30 –
the brachial and femoral artery pathways to reach a finger representing the included angle between the second dicrotic
transducer at a different time, as shown in Fig. 3(e). notch peak and its contiguous peaks – is also close to 1801.
Case V: Fig. 3(f) shows the PPG waveform in the presence of a Moreover, if the second notch peak is close to the next perfusion
PAC. Two rhythmic beats appear continuously, with the smaller peak, Pre_Ratio will be considered to lie within the normal HR
wave caused by the decreased preload from the premature beat. range. Therefore, Pos_Ratio was needed to distinguish the actual
In the usual methods, the PAC peak would be considered as the perfusion peak.
second peak, and the interval between the two peaks of the According to these observations, 21 fuzzy rules were designed
perfusion cycle would increase. to form the rule set of the FLD. The individual rule-based inference
process is supervised by computing the degree of match between
2.1.3. Fuzzy logic discriminator the fuzzified input values and the fuzzy set describing the
The FLD is designed to have three inputs: Pre_Ratio, Pos_Ratio, meaning of the rule-antecedent. The following rules represented
and y (the angle formed by three contiguous peaks). The fuzzy the specific inference:
term set for input Pre_Ratio comprises four membership functions:
BEST, GOOD, WORSE, and WORST. These fuzzy terms are defined If Pre_Ratio is BEST and y is ACUTE, THEN W is 1.
using triangular functions in the [0 2] subset of real numbers. The If Pre_Ratio is BEST and Pos_Ratio is GOOD and y is FLAT, THEN
fuzzy term set for input Pos_Ratio comprises two membership W is 1.
functions: GOOD and WORSE. These fuzzy terms are defined using If Pre_Ratio is GOOD and Pos_Ratio is GOOD and y is
trapezoid functions in the [0 2] subset of real numbers. The NOT_ACUTE, THEN W is 0.7.
fuzzy term set for y, which is also defined using triangular If Pre_Ratio is WORSE and Pos_Ratio is WORSE and y is OBTUSE,
functions defined in the [01 3601] subset of real numbers, THEN W is 0.4.
comprises four membership functions: ACUTE, NOT-ACUTE, FLAT, If Pre_Ratio is WORST and Pos_Ratio is WORSE and y is OBTUSE,
and OBTUSE. The triangular membership function mtriangular_i(x), THEN W is 0.
where x= Pre_Ratio or y, is defined by
8 As expressed in Eqs. (8) and (9), output m is produced by
> 0; x o li ; clipping the fuzzy membership functions, and the possibility
>
>
>
> xli
>
> li r x omi ; distribution function is then found by applying Mamdani’s max–
< m l ;
mtriangular_i ðxÞ ¼ xi þin ð8Þ min operator (Lin and Lee, 1996):
>
> i
>
> ; mi rx o ni ; r
>
> ni mi 
>
:
0; x Z ni ; mW ðwÞ  3 ½mPre _Ratio_i ðu0 Þ4mPos _Ratio_i ðv0 Þ4my_i ðy0 Þ4mWi ðw0 Þg;
i
where li and ni indicate the defined internal [li ni] of fuzzy term i,
ð10Þ
and m indicates the defined center of fuzzy term i. In other words,
mi in Eq. (8) represents the center of the triangular membership where the inputs are u0 =Pre_Ratio, n0 = Pos_Ratio, and y0 = y, the
function whose value is 1 at mi, and the functions (x–li)/(mi–li) and output is w0 =w, and r is the number of rules invoked. The
(  x+ ni)/(ni  mi) define the left spread and right spread of the technique of ‘center of gravity’ is used to process the defuzzifica-
triangle-shaped function mtriangular_i(x) on the internals [li, mi] and tion and to calculate the numerical output w of the FLD, as
[mi, ni], respectively. The trapezoid membership function expressed in Eq. (3):
mtrapezoid_i(x), x = Pos_Ratio is defined as Pm
j ¼ 1 mW ðzj Þzj
8 w ¼ Pm ; ð11Þ
>
> 0; x o lj ; j ¼ 1 mW ðzj Þ
>
>
>
> xl
>
> j
; lj r x omj ; where m is the number of quantization levels of the output, zj is
>
>
< mj lj
> the output degree at quantization level j, and mW(zj) represents
mtrapezoid_j ðxÞ ¼ 1; mj rx o nj ; ð9Þ the membership value in the output fuzzy set W, which is a
>
>
>
> x þ oj singleton.
>
> ; nj r x ooj ;
>
> oj nj
>
>
>
: 0; x Z oj : 2.1.4. Determining algorithm
Fig. 5 shows a flow diagram of the determining algorithm.
The output of the FLD is weighting factor W, which represents
First, Eq. (1) was applied to calculate the slope of the PPG
the degree of truthfulness of the current peak. The fuzzy term set
waveform, and the peak-to-peak interval, I, was found. The
for the weighting factor has four fuzzy terms of singleton type:
characteristic parameters of the slope signal (Pre_Ratio, Pos_Ratio,
X0 =0, X0.4= 0.4, X0.7 = 0.7, and X1=1.
and y) were calculated and fed into the FLD. Peaks for which the
There are two major concepts in constructing the fuzzy logic
output of the FLD is higher than 0.68 are considered to be actual
rules in the FLD. In Section 2.1.1 we described three parameters:
peaks of the perfusion cycle. PP is the Pre_PP
Pre_Ratio, Pos_Ratio, and y. Eq. (6) indicates that Pre_Ratio
approaches 0 as Pre_PP approaches N_PP, which means that the PP½n ¼ Pre _PP: ð12Þ
 ARTICLE IN PRESS
S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977 973

Fig. 4. The angle, y, formed by the three contiguous peaks for Case IV (1) and IV (2): (a) PPG waveform without a dicrotic notch and (b) PPG waveform with double dicrotic
notches.

Fig. 5. Flow diagram of the determining algorithm.

A normalized parameter is adjusted using Eq. (5), and the
algorithm will reset input parameters of the next peak using
Eqs. (2), (4), (6), and (7). Based on the determining algorithm, the
peak detector determined the perfusion peak of the raw PPG
waveform, P[n], by identifying the maximum value of the PPG
waveform following the actual peak of the slope signal. The HR of
beat-to-beat is calculated. An FLD output below 0.2 indicates a
missed beat condition or that the algorithm has worked
incorrectly. The algorithm will then reset the input parameters
of the next peak and determine whether the peak is an actual
 ARTICLE IN PRESS
974 S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977

HR (beats/minute)
120
100
80
60
40
20
0 20 40 60 80 100
Case I
HR (beats/minute)

120
100
80
60
40
20
0 20 40 60 80 100
Case II
HR (beats/minute)

100
80
60
40
20
0 20 40 60 80 100
Case III
HR (beats/minute)

140
120
100
80
60
40
0 20 40 60 80 100
Case IV (1)
HR (beats/minute)

120
100
80
60
40
0 20 40 60 80 100
Case IV (2)
HR (beats/minute)

120

80

40

0
0 20 40 60 80 100
Time (seconds)
Case V Manual
FLD
Correlation
Wavelet

Fig. 6. The HR extracted from the five cases, as shown in Fig. 3, by applying four detection methods: manual (black line), FLD (long dash or red line), correlation (short dash
or green line), and wavelet (dotted or blue line). (For interpretation of the references to colour in this figure legend, the reader is referred to web version of this article.)
 ARTICLE IN PRESS
S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977 975

ΔHR (beats/minute)
60
40
20
0
-20
-40
-60
-80
0 20 40 60 80 100
Case I
ΔHR (beats/minute)

40
20
0
-20
-40
-60
0 20 40 60 80 100
Case II
ΔHR (beats/minute)

30
20
10
0
-10
-20
0 20 40 60 80 100
Case III
ΔHR (beats/minute)

40
20
0
-20
-40
-60
0 20 40 60 80 100
Case IV (1)
ΔHR (beats/minute)

80
60
40
20
0
-20
0 20 40 60 80 100
Case IV (2)
ΔHR (beats/minute)

60
40
20
0
-20
-40
-60
-80
0 20 40 60 80 100
Time (seconds)
Case V FLD vs Manual
Correlation vs Manual
Wavelet vs Manual

Fig. 7. Difference in HR (DHR) between manual detection and the FLD, correlation, and wavelet extraction methods illustrated for the five cases shown in Fig. 6.
 ARTICLE IN PRESS
976 S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977

peak of perfusion cycle. PP is defined as in Table 2. RMSE is defined as follows:

vffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
u N
PP½n ¼ 0:5Pre _PP: ð13Þ u1 X
RMSE ¼ t ðx r Þ2 ; ð18Þ
An interpolated perfusion peak, P[n], will be inserted between Ni¼1 i i
the two contiguous perfusion peaks, P[n  1] and P[n +1]. When
where N is the number of beats, ri is the HR obtained by manual
the output value does not belong to the above-described cases,
detection, and xi is the HR extracted using FLD, correlation, or
the peak is considered to be a false peak. The input parameters of
wavelet detection. As shown in Fig. 7, all methods are sensitive to
the next peak are then adjusted using Eqs. (3), (4), (6), and (7).
large changes in the baseline PPG waveform. The RMSE values for
comparisons to the reference were 5.15, 10.79, and 7.48 beats/
min for FLD, correlation, and wavelet detection in Case I,
2.2. Wavelet filter respectively. The presence of double dicrotic notches in the PPG
waveform also readily interferes with the precision of the
A discrete wavelet transform (DWT) is defined as detecting method. The corresponding RMSE values for
  comparisons to the reference were 4.63, 7.17, and 13.08 beats/
DWTðm; nÞ ¼ x½k; cm;n ½k
min for FLD, correlation, and wavelet detection in Case IV (2),
respectively.
X 
¼ x½kc ½ðknam m
0 b0 Þ=a0 ; ð14Þ
k
4. Discussion and conclusions
where a ¼ am m
0 , b ¼ na0 b0 , t =kT, and k, m, nAZ (Fu et al., 2008). We
found that cðkÞ is the pulse response of the digital filter, so The PPG signal is easy to obtain from the tissue pads of the ears,
multiresolution filters could be achieved using the DWT. fingers, or toes where there is abundant superficial vasculature, and
Important information related to high-frequency levels can be it can provide important information about the cardiovascular
kept by applying a threshold value to the input to be filtered. The system (Wilkinson et al., 1998; Chellappan et al., 2007). Moreover,
Sth analysis level threshold value Zs is usually defined as follows: because it can be easily measured using optical technology, many
studies have used it to monitor HR changes or the pulse transit time
Zs ¼ u  maxf9Ds ½n9g; ð15Þ
for tests of physiological changes (Teng and Zhang, 2006). Although
where u as the threshold coefficient, and 0%u%1. We set u= 0.2, the PPG waveform is very similar to the blood pressure waveform, it
and perform six-times downsampling. can be readily contaminated by sudden position changes, intrave-
nous vasodilators, intermittent positive pressure breathing, or
cardiovascular diseases. This makes it more difficult to detect the
HR from the PPG waveform than from the blood pressure waveform.
2.3. Correlation detection
Correlation and wavelet methods are commonly used to smoothen
the PPG waveform, with peak detection based on a trigger level or a
The correlation signal was generated by shifting the one cycle window determining the peak index to extract the HR. However,
pattern, x, over the PPG signal, y, and simultaneously computing when the baseline PPG signal is highly variable or the PPG waveform
the correlation coefficient rxy[k] for each time index k= 1, y, N contains double dicrotic notches, the smoothed waveform will not
according to Suhrbier et al. (2006), the point of x is 500 appear like a sine wave, making it easy to miss actual peaks. Fu et al.
  sxy ½k (2008) only used the wavelet method to process 12 subjects whose
rxy k ¼ qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ; 1r r r 1; ð16Þ PPG signals almost belong to normal or Case II, and IV(1). Thus, the
s2x ½ks2y ½k performance was good. Fig. 7 shows that DHR is always large when
there is a large change in the baseline. Moreover, when the wavelet
or correlation method identified the mistaken peaks or missed
  1XN
sxy k ¼ ðx½kþ ixÞðy½k þiyÞ: ð17Þ actual peaks, the HR will continuously be wrong. Fig. 7(c) and (f)
Ni¼1
show that this can occur repeatedly in these methods.
Table 2 indicates that the performance of our designed detection
method using the FLD is more precise and stable than the other
methods of correlation and wavelet analysis. In the determining
3. Results algorithm, the normalized parameter, N_PP, is adjusted following a
change in HR, and an interpolated peak is inserted when an actual
peak is missed. This can avoid repeatedly incorrectly identifying
Fig. 6 shows the five cases that illustrate the differences
peaks or missing actual peaks. As shown in Fig. 7, the distortion
between tachograms derived by applying the different extraction
methods. In Cases I, II, and IV (1), the variable of beat-to-beat HR
is larger when the change of baseline of PPG waveform is larger. Table 2
RMSE values for various extraction methods compared to manual detection.
Moreover, because the wavelet method does not easily smoothen
the PPG waveform having the double dicrotic notches in Case IV Extraction method Number of beats RMSE vs. manual detection (beats/min)
(2), the double HR would occur. For Case V, the wavelet and
correlation methods all could not extract the accurate HR when Case I Case II Case III Case IV (1) Case IV (2) Case V
the PPG waveform has the presence of a PAC. In order to compare
Manual 147 122 123 168 108 129
the performance of these detection methods, the numbers of FLD 146 122 123 168 108 129
heart beats extracted by each detection method are listed in 5.15 2.36 0.05 0 4.63 0.08
Table 2. The differences in HR (DHR) between manual detection Correlation 144 118 123 165 108 95
(which was chosen as the reference) and the other extraction 10.79 7.93 3.44 8.24 7.17 17.70
Wavelet 134 122 127 135 109 111
methods are shown in Fig. 7 for the five cases. The root-mean- 7.48 3.02 9.40 1.08 13.08 3.16
square error (RMSE) values relative to the reference are presented
 ARTICLE IN PRESS
S.-H. Liu et al. / Engineering Applications of Artificial Intelligence 23 (2010) 968–977
duration of DHR is shorter for the FLD method than for the other
detection methods. In our experiments, we found that interference
from breathing, changes in amplitude, and the absence of the
dicrotic notch did not affect the precision and stability of extracting
the HR for these detection methods, as shown in Fig. 7(b)–(d).
However, changes in baseline, the presence of double dicrotic
notches, and cardiovascular diseases increase the likelihood of these
methods incorrectly identifying peaks or missing actual peaks. The
FLD algorithm is more robust than the other methods in Table 2.
In the proposed determining algorithm, reliability of FLD was used
as weight in the algorithm to determine the truthfulness of the peak
of the slope signal. The FLD effectively discriminates the effect of
artifacts caused by cardiovascular diseases or motion disturbances.
The fuzzy logic rules were obtained by observing many types of PPG
waveforms corresponding to the subjects with the different cases: (1)
large changes in the baseline PPG waveform, (2) changes in the
baseline and amplitude of the PPG signal due to breathing, (3) large
changes in the amplitude, (4) the presence of non-dicrotic notch or of
double dicrotic notches, and (5) the waveform being affected by
cardiovascular diseases. Hence, unlike normal general-purpose
smoothing methods, the proposed FLD embeds expert knowledge of
the PPG waveform into its structure and reasoning process.
In summary, we have proposed a new method using the FLD to
determine the truth of each peak of the slope signal as a weight,
and using this weight in a determining algorithm to determine
the actual peak of the perfusion cycle and adjust the input
parameters of FLD. Then, the peak detector determined the
perfusion peak of the raw PPG waveform and calculated the HR.
An interpolated peak was inserted near the time of the missing
peak, which allowed the beat to be monitored.
Acknowledgment
This work was supported by the National Science Council,
Taiwan, Republic of China, under Grant no. NSC 96-2221-E-324-
054-MY3.
References
Chellappan K., Zahedi E., Ali M.A.M., 2007. Effects of physical exercise on the
photoplethysmogram waveform. In: The 5th Student Conference on Research
and Development, Malaysia, 11–12 December.
977
Desai, M., Pena-Almaguer, E.D., Mannting, F., 2001. Abnormal heart rate recovery
after exercise as a reflection of an abnormal chronotropic response. Am. J.
Cardiol. 87, 1164–1169.
Fu, T.-H., Liu, S.-H., Tyan, C.-C., 2008. Heart rate extraction from the photo-
plethysmogram waveform using wavelet multi-resolution analysis. J. Med.
Biol. Eng. 28, 229–232.
Hayes, M.J., Smith, P.R., 2001. A new method for pulse oximetry possessing
inherent insensitivity to artifact. IEEE Trans. Biomed. Eng. 48, 452–461.
Huang, J.W., Lu, Y.Y., Nayak, A., Roy, R.J., 1999. Depth of anesthesia estimation and
control. IEEE Trans. Biomed. Eng. 46, 71–81.
Johansson, A., Oberg, P.A., 1999a. Estimation of respiratory volumes from the
photoplethysmographic signal. Part I: experimental results. Med. Biol. Eng.
Comput. 37, 42–47.
Johansson, A., Oberg, P.A., 1999b. Estimation of respiratory volumes from the
photoplethysmographic signal. Part II: a model study. Med. Biol. Eng. Comput.
37, 48–53.
Kim, B.S., Yoo, S.K., 2006. Motion artifact reduction in photoplethysmography
using independent component analysis. IEEE Trans. Biomed. Eng. 53,
566–568.
Lin, C.-T., Lee, C.S.G., 1996. Neural Fuzzy Systems: A Neural-Fuzzy Synergism to
Intelligent Systems. Prentice-Hall, Englewood Cliffs, NJ.
Lin, C.-T., Liu, S.-H., Wang, J.-J., Wen, Z.-C., 2003. Reduction of interference in
oscillometric arterial blood pressure measurement using fuzzy logic. IEEE
Trans. Biomed. Eng. 50, 432–441.
Murray, W.B., Forster, P.A., 1996. The peripheral pulse wave: information
overlooked. J. Clin. Monit. 12, 365–377.
Murrary, W.B., Gorven, A.M., 1991. Invasive vs. non-invasive blood pressure
measurements: the influence of the pressure contour. S. Afr. Med. J. 79,
134–139.
Nishime, E., Cole, C., Blackstone, E., Pashkow, F., Lauer, M., 2000. Heart rate
recovery and treadmill exercise score as predictors of mortality in patients
referred for exercise ECG. JAMA 284, 1392–1398.
Nakajima, K., Tamura, T., Miike, H., 1996. Monitoring of heart and respiratory rates
by photoplethysmography using a digital filtering technique. Med. Eng. Phys.
Lond. 18 (5), 365–372.
O’Rourke, M.F., Yaginuma, T., 1984. Waveflections and the arterial pulse. Arch.
Intern. Med. 144, 366–371.
Rhee, S., Yang, B.-H., Asada, H.H., 2001. Artifact-resistant power-efficient design
of finger-ring plethysmographic sensors. IEEE Trans. Biomed. Eng. 48,
795–805.
Suhrbier, A., Heringer, R., Walther, T., Malberg, H., Wesssel, N., 2006. Comparison
of three methods for beat-to-beat-interval extraction from continuous blood
pressure and electrocardiogram with respect to heart rate variability analysis.
Biomed. Tech. 51, 70–76.
Teng, X.-F., Zhang, Y.-T., 2006. The effect of applied sensor contact force on pulse
transit time. Physiol. Meas. 27, 675–684.
Watanabe, J., Thamilarasan, M., Blackstone, E., Thomas, J., Lauer, M.S., 2001. Heart
rate recovery immediately after treadmill exercise and left ventricular systolic
dysfunction as predictors of mortality. Circulation 104, 1911–1916.
Wilkinson, I.B., Cockcroft, J.R., Webb, J.D., 1998. Pulse wave analysis and arterial
stiffness. J. Cardio. Pharma. 3, 33–37.
Yamashita M., Shimizu K., Matsumoto G., 1995, Development of a ring-type vital
sign telemeter. Biotelemetry XIII.
Yu, C., Liu, Z., Mckenna, T., Reisner, A.T., Reifman, J., 2006. A method for automatic
identification of reliable heart rate calculated from ECG and PPG waveforms. J.
Am. Med. Inform. Assoc. 13, 309–320.