Measurement 196 (2022) 111211

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Measurement
journal homepage: www.elsevier.com/locate/measurement

A non-invasive heart rate and blood pressure monitoring system using

piezoelectric and photoplethysmographic sensors
Piyawat Samartkit a, Saroj Pullteap a, *, Olivier Bernal b
a
Department of Mechanical Engineering, Faculty of Engineering and Industrial Technology, Silpakorn University, Nakhon Pathom 73000, Thailand
b
LAAS-CNRS, Université de Toulouse, CNRS-INP, Toulouse 31000, France

A R T I C L E I N F O A B S T R A C T

Keywords: In this work, a non-invasive heart rate (HR) and blood pressure (BP) monitoring system using a lead zirconate
Blood pressure monitoring titanate (PZT) piezoelectric and photoplethysmographic (PPG) sensor has, preliminarily, been investigated. A
Modified pulse transit time modified pulse transit time (MPTT) is applied to demodulate HR, systolic blood pressure (SBP), and diastolic
Non-invasive health monitoring
blood pressure (DBP) from obtained BP waveforms. In addition, an engineering application software written by
Piezoelectric sensor
Photoplethysmographic sensor
LabView programming is, also, developed for dynamic signal monitoring and processing of desired parameters.
Consequently, HR and BP measurements on 15 volunteers are performed and validated against a reference digital
sphygmomanometer. The results show equivalent HR from both sensors with a mean absolute difference (MAD)
of 1.78 beats per minute. Meanwhile, MADs of SBP and DBP measurements are 2.62 and 1.36 mmHg, complying
with AAMI-BHS accuracy of “Grade A”, respectively. Therefore, PZT and PPG-based monitoring system could
lead to development of accurate, non-invasive, and low-cost HR and BP devices.

1. Introduction induced light absorption changes [9]. The aforementioned principle

Heart rate (HR) and blood pressure (BP) monitoring have become
important parameters for health indication and awareness of people. For
example, HR is monitored during exercises to optimize the training load
of athletes or otherwise used for stress management [1,2]. Meanwhile,
BP measurement allows early diagnosis, prevention, and treatment of
hypertension, a major cause of potential heart failures, strokes, and
mortality [3,4]. A digital sphygmomanometer is the basic health in­
strument widely utilized for HR and BP monitoring, owing to its non-
invasive technique, simple operation, and no need for medical super­
vision [5]. The major drawback of this device is, however, their inflat­
able cuffs, which occlude the arteries during the measurement. This
prevents continuous HR and BP monitoring to be performed and sub­
sequent use of the sphygmomanometer might damage the blood vessels
of the users [6]. Moreover, inappropriate cuff size could lead to less
measurement accuracy [7,8]. As such, new non-invasive devices have
been of interest in the biomedical field.
In recent years, photoplethysmographic (PPG) sensors have gained
considerable attention for the development of non-invasive and
continuous HR and BP monitoring devices. This is due to its simple
principle to detect blood volume variations in vessels by measuring the
does not require any inflatable cuffs, thereby PPG sensors are developed
for several biomedical applications [10]. For instance, Ding et al. [11]
applied a PPG sensor and electrocardiography (ECG) electrodes to es­
timate BP via pulse transit time (PTT) and PPG intensity ratio (PIR).
When compared to a finger cuff-based measuring device, the mean ab­
solute differences (MAD) in systolic blood pressure (SBP) and diastolic
blood pressure (DBP) were 4.09 mmHg and 3.18 mmHg, respectively.
Lazazzera et al. [12] also introduced a smartwatch utilizing dual PPG
sensors to monitor SBP and DBP in real-time, which had a satisfying
accuracy with MAD of <5 mmHg and standard deviation (S.D.) of lower
than 8 mmHg. Furthermore, Kao et al. [13] implemented a high-order
front-end filter to increase BP accuracy of PPG sensors, reducing the
MAD of SBP and DBP to as low as 2.8 and 1.2 mmHg, respectively, when
compared to a digital sphygmomanometer. A deep neural network al­
gorithm could additionally be applied to acquire high quality PPG
signal, as demonstrated by Slapnicar et al. [14], which allowed the
estimation of SBP and DBP with 9.43 and 6.88 mmHg of MAD,
respectively.
Nevertheless, PPG sensors are passive transducers, which consume
electricity to function and thus require a power source in operation [15].
Also, power overload could lead to sensor failure or might even damage

* Corresponding author.
E-mail address: saroj@su.ac.th (S. Pullteap).

https://doi.org/10.1016/j.measurement.2022.111211
Received 30 September 2021; Received in revised form 8 April 2022; Accepted 15 April 2022
Available online 19 April 2022
0263-2241/© 2022 Elsevier Ltd. All rights reserved.
P. Samartkit et al.
the user by overheating. Active transducers such as ECG electrodes,
however, reduces the power usage of the overall system. Still, these
sensors are dedicated biomedical instruments, which necessitate
complicate setup on patients. Modern smartwatches compensate for
such configuration with a single lead ECG (iECG) [16], activating by
placing a finger over a designated area of a properly worn watch. This,
nevertheless, means both hands are occupied, thus obstruct the user’s
activity during the BP measurement. In this case, alternative sensors
such as piezoresistive and piezoelectric could be applied instead, since
the devices could be worn on one hand without requiring any additional
gesture. Several researches have implemented these alternatives in the
acquisition of important cardiovascular parameters. Wang et al. [17], for
instance, proposed an array of piezoresistive sensors to detect the arte­
rial distension at the neck and wrist, which led to the measurements of
HR and BP. Likewise, Huang et al. [18] developed a highly sensitive
piezoresistive pressure sensor, which could monitor the BP waveform
continuously without any response delays. On the other hand,
Zambrana-Vinaroz et al. [19] presented a barometric transducer capable
of acquiring the human BP waveform through palpation at an arterial
site. These mentioned works have shown the viability of using pressure
sensors as an alternative to PPG sensor-based devices.
In previous work, a fiber optic-based Fabry-Perot interferometer
(FFPI) has been developed for HR and BP measurements [20]. While the
results show the possibility of using the FFPI sensor in vital signs
monitoring, An alternative system using cheaper conventional elec­
tronic sensors is also of interest. In this work, an HR and BP monitoring
system using a PPG sensor and piezoelectric sensor made of lead zirco­
nate titanate (PZT) has, preliminarily, been investigated. The PZT sensor
has been chosen due to its cheap cost, sufficient sensitivity to detect
arterial distension, and less power consumption. Moreover, it acts as an
active transducer similar to the ECG electrode, yet requires less gesture
in operation. Note that the power consumption of both sensors depend
on their respective signal conditioning circuit. Meanwhile, the PPG
sensor has, consequently, been widely applied to modern biomedical
technology, for examples, smartwatches, blood glucose monitors, pulse
oximetry sensors, etc. [9]. The developed system has, thus, implemented
a PZT alongside a PPG sensor to compare their suitability in BP wave­
form monitoring. In addition, this system applies the modified PTT
(MPTT) technique to estimate the SBP and DBP using the 2 proposed
sensors. Furthermore, an engineering application software has, also,
been developed via LabView programming to assist in dynamic moni­
toring of acquired BP waveform. The results of this work intend to
investigate the performance of the PZT and PPG sensor-based moni­
toring system as an alternative to the digital sphygmomanometer, which
could pave new ways for future development of non-invasive, real-time,
and low-cost HR and BP monitoring systems for biomedical engineering
applications.
2. Related theories
2.1. Brief of photoplethysmographic sensor
The principle of the photoplethysmographic (PPG) sensor is the
detection of light absorption by the tissue. Particularly, the light source
illuminates the desired body parts, where the target biocomponents (e.
g., blood cells) would absorb the light [10,14]. Here, illumination using
green light (~530 nm of wavelength) causes optical backscattering
which could be observed via a photodetector [21]. The operating prin­
ciple of this type of PPG sensor, also known as “reflectance mode PPG”
[10], could be illustrated in Fig. 1.
Incident light from the light source is absorbed by the blood cells
while the rest is backscattered to the PPG sensor. Since the blood volume
fluctuates according to the cardiac cycle, the absorption of light depends
on the amount of blood propagating through the illuminated area. In this
aspect, the back-scattered light intensity is inversely proportional to the
blood volume, as expressed by the Beer-Lambert law [22,23]:
2
Measurement 196 (2022) 111211
Fig. 1. Principle of PPG sensor in reflectance mode.
I = I0 e− β e− αd
(1)
where I0 is the intensity of incident light, α depicts the absorbance of the
tissues, β correlates to biological properties and optical path, and
d corresponds to the arterial diameter. For a PPG sensor to operate in
reflectance mode, at least a green light source, a photodetector, and a
power supply are required. Note that more light sources could be
installed to increase the illumination and subsequent back-scattering
intensity. However, this means more electricity would be consumed.
2.2. Overview of lead zirconate titanate piezoelectric sensor
This transducer, abbreviated as the PZT sensor, exploits the piezo­
electric effect to generate an electrical signal in response to the applied
mechanical force, pressure, strain, and vibration [24–26]. Basically, it is
comprised of 3 important components: a top electrode, a bottom metal
plate, and a PZT ceramic in between, as schemed in Fig. 2.
When the PZT ceramic is squeezed by induced pressure (P), an output
voltage (v) is generated by an amount determined by [27]:
v = Sv hP (2)
where Sv refers to the voltage sensitivity and h is the thickness of the PZT
ceramic. This principle could be applied for arterial distension sensing
and subsequent HR and BP monitoring. Another advantage of the PZT
sensor is its ability to generate a signal without an external power
source, which could lead to less power consumption of the monitoring
system.
2.3. Heart rate and blood pressure measurement technique
Generally, non-invasive heart rate (HR) and blood pressure (BP)
measurements rely on the same principle: the acquisition of arterial
pulse waveform (APW). As blood propagation corresponds to the cardiac
cycle, APW also indicates important cardiovascular parameters of a
person, as shown in Fig. 3.
From the figure, the APW can be categorized into 2 separate phases:
systole and diastole. During the former period, the heart contracts to
inject blood and BP rapidly rises until reaching the systolic peak, and the
BP at this point is defined as SBP. Afterwards, the heart enters the
diastole or relaxation phase with a noticeable decrease in BP. However,
the remaining energy within the arterial walls causes a subsequent in­
crease in BP, indicating a dicrotic notch between the systole and diastole
period. BP later reaches the dicrotic peak and then reduces to a baseline
value of DBP before the next cardiac cycle occurs [3].
In the case of HR measurement, the systolic peak is counted as it
corresponds to the heart pulse. Basically, counting the systolic peak over
60 s would give HR in beats per minute (bpm). Alternatively, this
operation could be completed in a shorter time by mathematical
P. Samartkit et al. Measurement 196 (2022) 111211

Fig. 2. Structure of lead zirconate titanate (PZT) sensor.

However, l, h, ρ, r, E, E0, and γ are subject-specific parameters yet

unobtainable through non-invasive means. As such, these variables are
treated as a coefficient determined through pre-calibration. Specifically,
“lρr/E0h” is treated as a single coefficient representing the subject-
specific parameters (a), and γ is annotated as b. These new coefficients
would be determined via pre-calibration of the monitoring system to a
standard BP device. Generally, PTT between 2 systolic peaks is applied
for both SBP and DBP measurements. In this work, a modified PTT
(MPTT) technique has, on the other hand, been utilized to consider an
additional parameter for the BP measurement. Consequently, the time
delay between the systolic peaks would lead to SBP calculation, while
Fig. 3. Typical arterial pulse waveform. using the dicrotic notches would give the DBP of a person. The equations
for SBP and DBP estimation are, thus, expressed in (6)–(7), respectively.
interpolation given by: 2
(
a
)
SBP = ln (6)
60 b PTTs
HR = N (3)
t ( )
2 a
DBP = ln (7)
where N is the number of counted systolic peaks and t corresponds to the b PTTd
measurement duration in seconds. This technique allows the measure­
ment to be performed faster with slight yet acceptable error. where PTTs denotes the PTT between systolic peaks, and PTTd is the PTT
Meanwhile, BP measurement depends on the demodulation tech­ between the dicrotic notches detected by the proximal and distal sensor.
nique of the APW. In this work, the basic principle of pulse transit time
(PTT) technique is applied and modified. As blood propagates rhyth­ 3. Experimental setup
mically throughout the body, there is a time delay when APW fluctuates
from one arterial site to another, which corresponds to BP [28,29]. By In this section, details of the developed HR and BP monitoring system
placing dual sensors at these two sites, the pulse transit time could be based on a PZT and PPG sensors are described in 3 main parts: system
defined, as could be shown in Fig. 4. designing and configuration, data processing, and performance valida­
Furthermore, PTT corresponds to the pulse wave velocity (PWV) tion through experimentations, respectively. The first part explains the
through the relationship described by the Moens-Korteweg and Hughes designing concept of the sensing and monitoring system, followed by the
equations as [11,30,31]: description of the data processing to obtain the desirable HR and BP
√̅̅̅̅̅̅̅ √̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅ results. The system validation for human HR and BP measurements are,
l Eh E0 eγBP h subsequently, detailed in the latter part.
PWV = = = (4)
PTT 2ρr 2ρr

where l indicates the length between the 2 arterial sites, E corresponds to
the Young’s modulus of the arterial wall, h is the wall thickness, ρ rep­
resents the blood density, r is the vessel radius, E0 indicates E at zero BP
value, while γ is the vessel coefficient. For simplicity, rearranging (4)
gives a general BP calculation in the form of:
( )
2 lρr
BP = ln (5)
γ E0 hPTT
Fig. 4. Basic principle of pulse transit time (PTT) technique.
3.1. Designing and configuration of developed system
The proposed system for HR and BP monitoring is comprised of a PZT
sensor from Murata model: 7BB-20-3 with 3.6 kHz resonant frequency
and a PPG sensor connected to their respective signal conditioning cir­
cuit. A microcontroller (Arduino UNO) is, consequently, utilized to ac­
quire and digitize the conditioned signals with 10 bits of analog-to-
digital converter (ADC) at 100 samples/seconds. These data are,
finally, transferred into the dedicated computer and then processed with
an engineering application software developed via LabView program­
ming, which allows the PPG and PZT waveforms to be recorded for
subsequent analyses. The configuration of the monitoring system is
illustrated in Fig. 5.
According to the configuration, the proximal PZT sensor (a) is placed
and then strapped to the user’s wrist without any underlying elements.
This ensures the arterial distension would properly be induced onto the
sensor by tightening the wrist strap. Once correctly fastened, the
circumference of the strap is marked using its scale for repeatable ex­
amination. Therefore, equivalent tightening force can be repeated for
subsequent examination. Meanwhile, a handheld probe is made with an

3
P. Samartkit et al.
Fig. 5. Configuration of PZT and PPG sensor-based HR and BP monitoring system.
embedded distal PPG sensor (b), which allows firm placement of the
thumb during the monitoring. Note that an additional circuit for the PZT
sensor (c) is separated from other components to initially amplify the
PZT output and also filter the signal noise. Other signal conditioning
circuits (d) are, subsequently, implemented to pre-process the raw PZT
and PPG signals. Ultimately, the microcontroller (e) is utilized to digitize
and transfer the pulse waveforms for monitoring and further process by
the computer (f). To emphasize signal and data processing, the purpose
of the aforementioned circuits is, however, expanded upon in the next
section.
3.2. Data processing for heart rate and blood pressure demodulation
The overall signal processing of the monitoring system from the
signal conditioning circuits to the digitized data could be shown ac­
cording to Fig. 6.
Although both PZT and PPG sensors could detect the APW of
humans, the retrieved signal strength is very small and prone to noises.
Therefore, the signal conditioning circuits are, next, employed. As
mentioned before, the PZT sensor has an additional circuit, which am­
plifies the sensing signal and also removes noise before further opera­
tions. Nonetheless, the rest of the signal conditioning of both PZT and
PPG signals are as follows: first, a high-pass filtering circuit with a 0.17
Hz cutoff frequency eliminates potential signal drift in the system.
Consequently, an approximately 52 dB signal amplification increases the
signal strength before a low-pass filtering circuit removes possible noises
of above 28 Hz. Since the human heart rate is approximately 60 bpm
Fig. 6. Signal processing procedures for HR and BP measurements.
4
Measurement 196 (2022) 111211
(equivalent to 1 Hz), another high-pass filtering circuit of 0.3 Hz cutoff
frequency is, therefore, implemented to filter out leftover signal drift
due to minor motion artifacts (e.g. breathing and slight muscle
contraction). Once the signal conditioning process is completed, the
microcontroller digitizes the PZT and PPG signals to be displayed using a
LabView-based engineering application software. An example of its user
interface is shown in Fig. 7.
In particular, the engineering application software is developed with
5 main interfaces as follow: (a) run or stop function, (b) configure the
period in which the signals would be displayed and recorded, (c) export
the APWs to spreadsheet files (.xlsx) for subsequent analyses, (d) real-
time display of PZT and PPG signals, and (e) recorded waveforms over
a configured period from 0 to 60 s. Note that after monitoring the signals
for a set period of time, HR could be automatically indicated. To prevent
potential errors, both PZT and PPG signals are applied for the HR
calculation using (3), which allows the user to validate the results.
Meanwhile, PTTs and PTTd are determined elsewhere via the exported
data. This gives more flexibility to the analysis, since parameters other
than the mentioned PTT could be investigated as well. A moving average
function and also a peak detection algorithm, included in the developed
software, have been employed to eliminate undesirable signal noise, and
indicate the essential systolic peaks and dicrotic notches, respectively.
Afterwards, the pre-calibration of the monitoring system could be per­
formed, leading to the calculation of the user’s SBP and DBP. In this case,
the method of pre-calibration would be detailed in the experimentation
part.
3.3. Performance validation
To verify the developed system, 15 human volunteers have partici­
pated under their consent. They are instructed to sit and lay both of their
arms on a flat surface before the PZT and PPG sensors are set up on their
left arm, accordingly demonstrated in Fig. 5. In this investigation, a
digital sphygmomanometer (Omron HEM-7130) is utilized as a pre-
calibration instrument and a reference device. Here, the monitoring
on each volunteer starts by completing the procedure as follows:
• The APW acquired through PZT and PPG sensors are applied for PTTs
and PTTd calculations. Then, the sphygmomanometer measures the
SBP, DBP, and HR of the volunteers.
• Afterwards, all determined parameters are applied in (6)–(7), which
consequently determines the pre-calibration values of a and b of the
volunteer.
P. Samartkit et al. Measurement 196 (2022) 111211

Fig. 7. User interface of HR and BP monitoring system with dedicated functions: (a) run/stop button, (b) display period setting, (c) data export option, (d) real-time
display, and (e) record of acquired waveforms over a set period.

• The above processes are repeated for 3 times to compensate for any
BP and PTT changes during the pre-calibration. Subsequently, an
average value of the coefficients a and b are acquired for each
volunteer.
The continuous HR and BP monitoring are performed for a duration
of 60 s at a time, sequentially followed by the operation of the reference
device. This procedure is carried out for 3 times of repeatability, thereby
a total of 45 datasets are obtained. To compensate for the arterial oc­
clusion, reference readings adjacent to each continuous monitoring
result are averaged for the validation. The results from both measuring
instruments are later compared against one another to investigate the
performance of the proposed system. Here, the mean absolute difference
(MAD) is applied to assess the accuracy of the developed system by using
the expression of [32]:
1∑ M
MAD = |χ − χ t |
n n=1 m
differs from the BHS, the lower grade is suggested for the proposed BP
device. These BP validation protocols are considered for several BP
measuring devices [35–37]. Important to note is that the AAMI-BHS
standard requires at least 85 subjects with varying BP levels for the
device validation. In this work, 15 volunteers have, however, been
recruited to preliminarily investigate the developed PZT and PPG-based
system before future clinical trials. To achieve this, the system should
attain at least a “Grade B” accuracy for the passing criteria.
Regardless, an additional experiment is performed to validate the
repeatability of the PZT and PPG sensor-based monitoring system in
daily usage. In this case, 3 volunteers have participated for 7 days long
term examination, where their HR and BP are measured according to the
previously described procedure. However, the pre-calibrations of co­
efficients a and b are obtained through 3 different methods: determined
only once on the first day, pre-calibrated every day throughout the 7
days, and averaged once the examination is over.
(8)
4. Experimental results and discussion

where χ m is the BP value measured by the developed system, χ t is the BP During the experiment, the proposed monitoring system can,
given by the reference device, n represents the test number, and M in­ continuously, detect and record the APW obtained from both PZT and
dicates the total number of measurements. Consequently, the MAD re­ PPG sensors in real-time. Examples of these are illustrated in Fig. 8. Note
sults are categorized using the grading criteria set by the Association for that the amplitude of the PPG signal is inverted to show its similarity to
the Advancement of Medical Instrument (AAMI) and the British Society the actual APW, which eases the detection of important APW charac­
of Hypertension (BHS), as displayed in Table 1 [33,34]. teristics such as the systolic peaks and dicrotic notches.
From the table, the grading is achieved when the resulting MAD and From Fig. 8(a), the first peaks of each PZT and PPG signal denote the
cumulative percentage of absolute difference are within the specified systolic peaks, which are considered as the number of heart pulse (N)
values. Here, an instrument which passes the AAMI criteria must, also, and parameters for PTTs measurement. In Fig. 8(b), the PTTd is
have MAD and standard deviation (S.D.) of lower than 5 mmHg and 8 measured as the time difference between the dicrotic notches or the
mmHg, respectively. To pass the BHS criteria, however, the accuracy of inflections between the first and second signal peaks. In the case of the
at least “Grade B” must be fulfilled [35]. In case the grading from AAMI examples, PTTs and PTTd are found to be ~0.11 and ~0.12 s, respec­
tively. These PTT parameters are, consequently, applied for the pre-
calibration process and later the subsequent SBP and DBP de­
Table 1 modulations. This also proves that PZT and PPG sensors can detect APW
AAMI-BHS grading criteria for BP measuring devices [33,34]. and obtain vital cardiovascular parameters for further analyses.
Grade AAMI criteria BHS criteria It should be noted that the PZT sensor utilizes less energy during the
Criteria MAD within certain range Cumulative percentage of absolute difference measurement, as no power supply is required. This also lowers accidents
within:
from sensor overheating over long periods of operation, improving the
<5 mmHg <10 mmHg <15 mmHg overall safety of using the system. This encourages the adoption of the
A ≤4 mmHg ≥60% ≥80% ≥95% PZT sensor for energy-efficient HR measurement applications. Here, an
B 4–6 mmHg ≥50% ≥75% ≥90% experiment using a PZT sensor instead of the PPG at the thumb has been
C 6–7 mmHg ≥40% ≥65% ≥85% carried out. It is found that the APW can also be continuously detected
D ≥7 mmHg Worse than C
comparable to the PPG signal. This, thus, implies that the use of dual PZT

5
P. Samartkit et al. Measurement 196 (2022) 111211

Fig. 8. Examples of PZT and PPG signals for (a) PTTs measurement and (b) PTTd measurement.

or PPG sensors could be implemented. However, the thumb must be been performed on 15 volunteers to allow further demodulation. A total
tightly strapped to the PZT sensor, as the finger compression is explicitly of 45 SBP and DBP calculations using (6)–(7) have, consequently, been
revealed. This would eventually cause discomfort to the subject and carried out, with the results summarized in Fig. 10.
leads to unintentional movements, resulting in significant measurement Fig. 10(a) shows the overall BP measurement results, while the ac­
errors. Therefore, the PPG sensor might be more suitable for APW curacy validations of SBP and DBP have been illustrated in Fig. 10(b)–
monitoring at the thumb and fingertips, due to its non-occlusive design. (c), respectively. Consequently, it found that the developed monitoring
On the other hand, the signal conditioning circuits utilized for the PZT system has highly accurate SBP and DBP measurement capabilities with
and PPG sensors are similar. This is to prevent any potential signal de­ MAD ± S.D. of 2.62 ± 1.92 mmHg and 1.36 ± 1.05 mmHg, respectively.
lays, which would consequently cause an error to the PTTs and PTTd Furthermore, the percentages of absolute difference in SBP under 5, 10,
measurements. Nevertheless, the pre-calibration of PTT using a and 15 mmHg are 86.67%, 100.00%, and 100.00%, respectively.
population-based BP might compensate for this bias, thus would not
result in erroneous BP readings. This topic is of interest for the future.
After monitoring all volunteers, their HR, SBP, and DBP are
demodulated. In the former measurement, the results given by the PZT
and PPG sensors have been compared with one another and also with the
reference sphygmomanometer. These are summarized in Fig. 9.
Incidentally, the HR obtained from the PZT and PPG signals are
equivalent, implying that the proposed monitoring system could utilize
any sensors for HR monitoring. Once compared to the reference device,
the mean absolute difference (MAD) in measurement is 1.78 bpm with a
standard deviation (S.D.) of 1.98 bpm, respectively. Additionally,
93.33% of all acquired HR through both PZT and PPG sensors are within
the accuracy range of the sphygmomanometer, shown by the error bars
[38]. In this case, the difference in HR values is due to the different
techniques employed in the measurements. Since the digital sphygmo­
manometer operates no longer than 30 s, the given HR is estimated via a
built-in algorithm, whereas the PZT and PPG sensor-based monitoring
system performs the measurement over 60 s to give an actual HR of a
person. The latter, however, does not require an inflatable cuff and can
also display the dynamic APW of a person in test. This means the
developed system can continuously measure HR without arterial oc­
clusion, in contrast to the digital sphygmomanometer. Since HR
measured by the PZT and PPG-based system is obtained via systolic peak
detection, the developed system could, therefore, monitor APW with
high accuracy for subsequent BP measurement.
In BP measurement, the pre-calibration of the developed system has

Fig. 10. BP validation results: (a) overall BP measured from reference and
proposed system, (b) absolute difference in SBP readings, and (c) absolute
Fig. 9. Summary of HR measurement results. difference in DBP results.

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P. Samartkit et al.
Meanwhile, the DBP measurement shows all aforementioned results of
100%. The overall BP measurement accuracy of the monitoring system
is, therefore, categorized as “Grade A”, according to Table 1. This shows
that the proposed PZT and PPG-based system is capable of highly ac­
curate BP measurement, and is suitable for further development in the
biomedical field.
To further validate the repeatability of the proposed system for long-
term BP monitoring, the 7 days long examination on 3 volunteers is
investigated. The validation results are, consequently, summarized in
Table 2.
From the table, it is observed that performing daily pre-calibration of
the monitoring system provides the least MAD ± S.D. in both the SBP
and DBP calculations of 2.53 ± 2.38 mmHg and 2.56 ± 2.34 mmHg,
respectively. However, the pre-calibration only on the 1st day yields
higher errors in both SBP and DBP of 9.76 ± 9.25 mmHg and 8.81 ±
8.52 mmHg. This means that the cardiovascular parameters of the vol­
unteers could change every day. Further analysis shows that PTTs and
PTTd of every volunteer vary daily even though their SBP and DBP do
not significantly change from the previous day. As such, daily pre-
calibrations cause lower error than other methods, as the subject-
specific coefficients (a and b) are changed to reflect the intrinsic car­
diovascular parameters of the volunteer in each day. It confirms that the
mentioned cardiovascular parameters could not be determined only
once, and frequent pre-calibration should be performed to ensure the
accuracy of measurement. However, this method could be exploited in
ambulatory BP measurement where a sphygmomanometer is generally
operated every 15 min for 24 h. In this case, the sphygmomanometer
could be used to perform regular pre-calibration (e.g., for every 4 h),
while the developed system measures BP during the interval. This would
reduce the number of times the former device must be applied, thus
decreasing the arterial occlusion and discomfort from using the inflat­
able cuff. This alternative application might lead to improved ambula­
tory BP measurement in the future. To this end, the lead component of
the PZT ceramic should be addressed before implementing this design.
As such, future HR and BP monitoring system could compensate by
constructing a sensing probe/wristband containing the PZT sensor to
prevent direct exposure and potential harm to the human.
In another aspect, the proposed MPTT technique in this work in­
troduces an alternative BP demodulation scheme. Its advantages and
also limitations compared to other techniques of similar instrumentation
are, consequently, summarized in Table 3.
Conventional pulse wave analysis (PWA) method requires single PPG
or PZT sensor to perform. It, however, cannot readily demodulate all
desirable readings without other BP device. The setup is also cumber­
some and might provide inaccurate results in long-term examination.
Meanwhile, PTT technique compensates for easier configuration and
demodulation. Nevertheless, only one PTT is applied for both SBP and
DBP demodulation, thus it might not represent real-life human cardio­
vascular parameters. In contrast, the proposed MPTT technique exploits
2 PTT values from 2 different APW characteristics to separately
demodulate SBP and DBP. This provides more parameters for interpre­
tation and subsequently leads to possible accuracy improvement. Still,
high-performance system is required to detect important pulse charac­
teristics in real-time for ease of use. From this context, the MPTT could
be motivated as an improved BP demodulation technique for the current
Table 2
Validation results of pre-calibration methods over 7 days long BP examination.
Parameters of interest Pre-calibration method
Method 1: Method 2:
(Only on 1st day) (Perform daily)
SBP results MAD (mmHg) 9.76 2.53
S.D. (mmHg) 9.25 2.38
DBP results MAD (mmHg) 8.81 2.56
S.D. (mmHg) 8.52 2.34
7
Measurement 196 (2022) 111211
Table 3
Advantages and limitations of modified pulse transit time and similar demod­
ulation techniques.
BP demodulation Advantages Limitations
technique
(a) Pulse wave – Only requires a sensor to – Cannot readily
analysis (PWA) perform (either PPG or demodulate all desired BP
PZT) without other instrument
(b) Pulse transit – Non-occlusive – Only a parameter is
time (PTT) configuration demodulated into both
Easily implemented SBP and DBP
with general electronics
(c) Modified pulse – Obtain more than a – Requires high-
transit time parameter to performance system to
(MPTT) demodulate SBP and interpret in real-time.
DBP
Leads to improved
accuracy
and emerging biomedical engineering applications.
5. Conclusion
In this work, a non-invasive dynamic HR and BP monitoring system
using a PZT and PPG sensors has been investigated. Here, a modified
pulse transit time (MPTT) technique has been applied to demodulate the
time delay between systolic peaks and dicrotic notches into systolic
blood pressure (SBP) and diastolic blood pressure (DBP), respectively.
An engineering application software has, also, been developed to assist
in the operation, which has proven useful for continuous monitoring and
recording of the important PZT and PPG signals during the performance
validation on 15 volunteers. Consequently, the proposed system could
measure the HR with a mean absolute difference (MAD) and standard
deviation (S.D.) of 1.78 and 1.98 beats per minute, respectively, when
compared to a reference digital sphygmomanometer. In addition,
93.33% of all HR measurements are within the accuracy range of the
reference device. This confirms that the developed system has high ac­
curacy in HR measurement when using either the PZT or PPG sensor.
Note that the PZT element does not require a power supply to operate,
thus would consume less energy while providing safety insurance
against sensor overheating during long periods of operation. This might
provide an alternative of using dual PZT sensors. The PPG sensor,
however, might be more suitable for arterial pulse waveform monitoring
at the thumb or fingertips, due to its non-occlusive design. Otherwise,
the SBP and DBP results measured from 45 datasets show MADs of 2.62
mmHg and 1.36 mmHg, respectively. These results suggest the accuracy
of the developed monitoring system complies with the AAMI-BHS
grading of “Grade A”. Therefore, the monitoring system exhibits high
accuracy in HR and BP measurement and is suitable for further devel­
opment into a novel biomedical device. After the 7 days long exami­
nation on 3 volunteers, it is found that pre-calibration of the PZT and
PPG sensor-based system should be performed daily to ensure the ac­
curacy in BP measurement. In this perspective, the proposed system
might provide a more comfortable alternative during ambulatory BP
measurement, as it could reduce the use of a sphygmomanometer over
the 24 h long operation. Therefore, the developed PZT and PPG sensor-
based monitoring system could pave new ways for the development of a
continuous HR and BP monitoring device for commercial biomedical
applications. Additionally, MPTT technique could become a potential BP
demodulation technique for the development of future high-accuracy
devices for the current and emerging biomedical engineering
applications.
CRediT authorship contribution statement
Piyawat Samartkit: Investigation, Validation, Writing – original
draft. Saroj Pullteap: Conceptualization, Methodology, Software,
P. Samartkit et al.
Writing – review & editing, Supervision. Olivier Bernal: Resources,
Methodology, Validation.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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