Biomedical Signal Processing and Control 75 (2022) 103581

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Biomedical Signal Processing and Control

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

Attention-based residual improved U-Net model for continuous blood

pressure monitoring by using photoplethysmography signal
Mingzheng Yu a, 1, Zhiwen Huang a, 1, Yidan Zhu b, Panyu Zhou c, Jianmin Zhu a, *
a
School of Mechanical Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
b
School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an 710049, China
c
Department of Orthopedics, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai 200433, China

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

Keywords: Blood pressure (BP) is an important clinical indicator for cardiovascular health assessment, and accurate
Blood pressure monitoring monitoring of continuous BP is still a challenging task. In this paper, an attention-based residual improved U-Net
Photoplethysmography signal (ARIU) model is proposed to improve the accuracy of continuous BP monitoring by using the photo­
Deep learning
plethysmography (PPG) signal. This model consists of an improved U-Net employed to learn the high dimen­
Attention mechanism
Residual mechanism
sional features from PPG signal, an attention module embedded in the skip connections to reduce redundancy of
learning features, and a residual module replaced common convolution to prevent degradation problems and
enhance generalization performance. The raw PPG signals and arterial BP download from the MIMIC-III data­
base, the first and second derivatives of PPG signal are utilized as additional inputs to increase the multiform of
input information, and a data input way of parallel-based fusion are adopted to improve the effectiveness of
information mining. After data preprocessing, the dataset used in this study contains 150,000 samples, belonging
to 100 subjects. The reliability of the proposed model is verified by the ablation experiments, and the
advancement of the model is demonstrated by the comparison experiments with other state-of-art methods. The
mean absolute error (MAE) and standard deviation (STD) of systolic blood pressure (SBP) predicted by the
proposed model are 4.75 mmHg and 6.72 mmHg respectively, and that of diastolic blood pressure is 2.81 mmHg
and 4.59 mmHg. The results meet the requirements of the Advancement of Medical Instrumentation (AAMI) and
reach the “Grade A” of the British Hypertension Society (BHS) protocol.

1. Introduction
Cardiovascular disease (CVD) is a serious health problem that causes
millions of deaths every year around the world [1], and blood pressure
(BP) is the main clinical symptom used to detect, diagnose or monitor
cardiovascular and hemodynamic diseases [2,3]. Therefore, BP moni­
toring is very necessary for the prevention, control, and research of these
diseases.
According to the different measurement techniques, the BP moni­
toring method can be divided into three categories: direct BP monitoring
method, intermittent BP monitoring method, and continuous BP moni­
toring method [4]. Direct BP monitoring method, also known as a direct
measurement with an intra-arterial catheter, is an invasive monitoring
approach [5], and its measurement result is considered as the “gold
standard” [6], but due to the disadvantages of complications and high
technical requirements, this approach is only suitable for the patients
under major surgery or critical care [7,8]. Intermittent BP monitoring
method mainly includes the Korotkoff method and the oscillometric
method, which also can reach high accuracy [9], but have the disad­
vantages of insufficient ability to track and reflect the instantaneous and
continuous BP changes. In contrast, the continuous BP monitoring
method can monitor the continuous BP change in the daily environment,
and the measurement results are closer to the real situation of the human
body with more physiological effectiveness and monitoring accuracy
[10,11].
At present, continuous BP monitoring methods used in cardiovas­
cular health management mainly include arterial tonometry method,
volume clamp method, pulse wave velocity (PWV) or pulse wave transit
time (PWTT) measurement method, and pulse wave parameter mea­
surement method [12,13]. The arterial tonometry method uses pressure

* Corresponding author.
E-mail address: jmzhu_usst@163.com (J. Zhu).
1
Contributed equally to the work.

https://doi.org/10.1016/j.bspc.2022.103581
Received 24 September 2021; Received in revised form 28 January 2022; Accepted 12 February 2022
Available online 23 February 2022
1746-8094/© 2022 Elsevier Ltd. All rights reserved.
M. Yu et al.
sensors pressed directly against the skin to measure the pressure pulse
wave and calculate BP [14], but it is difficult to always maintain the
precise measurement position of the sensor and susceptible to motion
artifacts [15]. The volume clamp method follows the principle of the
relaxed wall of the vessel and uses the counter-pressure instead of the
artery pressure, but the measurement accuracy is affected by observa­
tion position. PWV or PWTT measurement method respectively utilizes
propagation speed or propagation time to calculate arterial BP and
generally requires at least two sensors to collect relevant physiological
signals, such as electrocardiogram (ECG) signals and pulse wave signals,
but multi-sensors is inconvenient to deploy and monitoring accuracy is
limited by synchronization algorithms of sensors. The pulse wave
parameter measurement method uses the characteristic information
related to pulse wave waveform to establish the correlation between the
waveform and BP, which is the research hot spot for high precision non-
invasive BP monitoring and needs to be further studied.
Due to the advantages of simple operation, stable performance, and
strong adaptability, photoplethysmography (PPG) has been gradually
used for non-invasive continuous BP monitoring, which can detect the
changes of blood volume in human microvessels [16] and contains rich
cardiovascular information [17]. Teng et al. [18] extracted manual
features from a single PPG signal and used a linear regression method to
estimate BP, which achieved good monitoring accuracy. Zadi et al. [19]
established the autoregressive moving average (ARMA) model based on
the peak and valley waveform features of the PPG signal to estimate
systolic blood pressure (SBP) and diastolic blood pressure (DBP), which
obtained good predicting results. Li et al. [20] used semi-classical signal
analysis (SCSA) to extract features from PPG signal and then developed
and compared three machine learning methods to estimate BP, which
revealed support vector machine (SVM) algorithm overall achieved the
best estimation accuracy. Kurylyak et al. [21] extracted 21 feature pa­
rameters from the PPG signals and established an artificial neural
network (ANN) model to estimate continuous BP, which achieved better
results than the linear regression method. However, the handcrafted
features in these studies make the PPG signals lose the potentially sen­
sitive features to some extent, which hindered the further improvement
in accuracy of continuous BP monitoring.
With the powerful capabilities of data mining and feature extraction
[22,23], deep learning has gradually been applied to the field of
continuous BP monitoring based on the PPG signals. Shimazaki et al.
[24] used an auto-encoder to extract features from the PPG signals and
employed a multi-layered neural network (MNN) model to estimate BP,
and the accuracy is better than the multiple regression analysis (MRA)
model. But the methods still did not get rid of the limitations of the
feature engineering. Some researchers directly employ the deep learning
model to adaptively extract high-dimensional features from the PPG
signals. Slapničar et al. [25] proposed a deep neural network model to
estimate BP based on time–frequency information fusion, which ach­
ieved better results than the random forest model based on manually
extracted features from the PPG signals. Harfiya et al. [26] designed an
auto-encoding model based on Long Short Term Memory (LSTM) to
monitor the continuous BP by using the raw PPG signals, and the results
met the requirements of the Advancement of Medical Instrumentation
(AAMI) standard. Although these deep learning methods can work more
effectively than traditional methods, there is still space for further
improvement in the data mining of PPG signals.
Recently, Ronneberger et al. [27] proposed the U-architecture con­
volutional network (U-Net) for biomedical image segmentation, which
had been attracted the attention of some researchers and helped them to
solve many challenges in various fields. Athaya et al. [28] introduced
the U-Net into the continuous non-invasive BP monitoring based on the
raw PPG signals, which obtained better estimate results than the other
compared methods and met the requirements of the AAMI and the
British Hypertension Society (BHS) standards. However, the classic U-
Net still has some shortcomings for mining the PPG signals. On the one
hand, the U-Net implements the high-low scale feature fusion of the PPG
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Biomedical Signal Processing and Control 75 (2022) 103581
signals through skip connections between the contracting and expansive
path, but the direct fusion of feature information at different scales will
inevitably generate some inefficient or redundant information for BP
monitoring. On the other hand, the conventional convolution operations
in the classic U-Net generally have the information loss and vanishing
gradient, which reduced the effectiveness of feature extraction from the
PPG signals [29]. Aiming at the shortcomings of the classic U-Net model,
a handful of researchers have made new improvements to the model
structure [30,31]. Although these optimizations have achieved good
results in the research fields, such as image segmentation, the
improvement of the model is still beginning and developing in contin­
uous BP monitoring by using physiological signals.
Relevant researches show that the first derivative of the PPG signal
(VPG) and the second derivative of the PPG signal (APG) can provide
additional potential information for improving the accuracy of BP esti­
mation [32]. Shimazaki et al. [33] used the serial combination of the
PPG, VPG, and APG signals to estimate cuffless BP, which achieved
higher accuracy than only using the separate PPG signal. Slapničar et al.
[25] used the PPG, VPG, and APG signals to train their proposed
network respectively, and further trained the network after fusing the
features obtained from the three signals, which obtained better results
than the separate PPG signals. Nevertheless, these studies didn’t
consider the synchronization and correlation between the PPG, VPG,
and APG signals in the time domain, so the utilization of these potential
information also needs to be further improved.
In order to address the aforementioned problems and further
improve the accuracy of non-invasive BP monitoring, an attention-based
residual improved U-Net (ARIU) model by using the parallel-based
fusion of PPG, VPG, and APG are proposed to monitor continuous BP.
The main contributions of this paper are outlined as follows:
(1) An ARIU model was proposed to monitor continuous BP by using
the PPG signals, which the improved U-Net was employed to
learn multi-scale features, the attention module was utilized to
reduce redundant features, and the residual module was used to
prevent performance degradations.
(2) Considering the synchronization and correlation in the time
domain, the parallel-based information fusion of the PPG, VPG,
and APG signals can improve the efficiency and effectiveness of
feature extraction.
(3) The proposed model was validated by ablation and comparison
experiments. Compared with other state-of-art methods, the
proposed model can obtain higher accuracy of BP monitoring.
The rest of this paper is organized as follows. Section 2 describes the
used dataset and the model for BP monitoring. The experiment and
result analysis are provided in Section 3. The conclusion are drawn in
Section 4.
2. Materials and methods
In this Section, the overall framework of the proposed continuous BP
monitoring method is shown in Fig. 1. This method mainly involves the
data preparation phase and model building phase, which concretely
includes data acquisition, data preprocessing, dataset setup, model
designing, and model training.
In the data preparation phase, in order to ensure the sufficiency and
richness of the samples, the PPG signals and their corresponding BP
records are downloaded firstly from the public Medical Information
Mart for Intensive Care III (MIMIC-III) database. Then, data pre­
processing is used to eliminate motion artifacts and distortions of the
original data. Next, in order to mine more effective information from
preprocessed data, the VPG and APG signals are calculated and fused in
parallel with the PPG signal, which is regarded as a single set of input
data. Besides, the corresponding SBP and DBP of each sample are
calculated and regarded as the label of the subsequent proposed model.
M. Yu et al.
Fig. 1. The overall framework of the proposed continuous BP monitoring method.
In the model building phase, the ARIU model is designed to learn
high dimensional features from input signals adaptively, and the 5-fold
cross validation strategy is utilized to train the designed model. In
addition, the hyperparameters of the proposed model are adjusted ac­
cording to the training results. Ultimately, after performance evaluation
on the testing dataset, the model that met the performance requirements
is used for continuous BP monitoring.
2.1. Data preparation
2.1.1. Data acquisition
The dataset used in this study comes from the MIMIC-III waveform
database [34,35], which contains 67,830 records of about 30,000 ICU
patients, and almost all of these records consist of various digital
physiological signals (such as ECG signals, BP signals, respiratory sig­
nals, PPG signals, and other physiological signals). Each record corre­
sponds to the physiological signals of an individual patient during the
whole hospitalization period. In this study, a total of 230 patients’ raw
data are downloaded from this open database, and the data of each
patient contains the PPG signals and the corresponding BP signals with a
sampling rate of 125 Hz with 8-bit, 10-bit, or 12-bit (occasionally) res­
olution. The lengths of these records also vary, most are a few days in
duration, but some are shorter and others are several weeks long.
2.1.2. Data preprocessing
The physiological signals from the MIMIC-III database contain a lot
of noises, such as motion artifacts and distortions. No doubt that the 230
patients’ raw data downloaded in our study also have quality problems,
such as distorted signal (flat lines and flat peaks, etc) or motion artifacts,
so the preprocessing is indispensable for the acquired data.
To ensure data synchronization between PPG signals and BP signals,
the acquired data are firstly divided into numerous sample segments
according to the null position of the raw continuous signal. Each sample
segment that contained the abnormal data points (including flat lines,
flat peaks, etc.) is discarded to improve the efficiency of data processing.
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Biomedical Signal Processing and Control 75 (2022) 103581
In this part, we refer to the preprocessing method of other research [25].
As a widely used data stream smoothing and denoising method, the
Savitzky-Golay filter can retain the distribution characteristics of rela­
tive maximum, minimum, and width in the time domain [36]. There­
fore, this filter is employed to eliminate abnormal mutation values and
high-frequency noises in each reserved sample segment of PPG and BP
signals. Then, based on the peak and valley detection algorithm pro­
posed by Elgendi et al. [37], the effective peak and valley points of each
filtered sample segment. According to the detected points, the data be­
tween two consecutive valley points in each sample segment is regarded
as one cycle. Moreover, if two valley points are too far or too close, this
data of one cycle will be skipped. Next, the data with five consecutive
cycles (e.g., from the first valley point to the sixth valley point) are
further segmented into one independent sample. And there is no overlap
between two consecutive samples of five cycles. If the number of sam­
ples for a patient does not exceed 1500, then this patient’s data should
be discarded. In the end, if>1500 data segments are obtained from all
the records of each patient, then these data segments of this patient have
been shuffled and 1500 data segments have been randomly selected.
After the above preprocessing work, the number of patients in our
dataset dropped from 230 to 100. Besides, for the PPG signal of each
sample, the normalization is used to reduce its range to the interval of
[0,1], which is shown in:
xi − xmin
xnorm = (1)
i
xmax − xmin
Finally, since the input of the subsequent deep neural network model
generally requires the same length, and the actual sampling points of the
PPG signal of each sample which contains five consecutive cycles are
always inconsistent, such as three examples with different lengths as
shown in Fig. 2. Therefore, this study uses the cubic spline interpolation
method to establish a fitting function for the raw PPG signal of each
normalized sample, then uses the fitting function to take fixed-length
sampling points on the raw PPG signal of the sample. In this study,
based on preliminary experiments, the length of sampling points is set to
M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

Fig. 2. Diagram of the resampling process for examples under different bpms.

600. Moreover, the examples from top to bottom in Fig. 2 respectively in each segment. Concretely, the example of PPG, VPG, and APG signal
correspond to a heart rate of 144 beats per minute (bpm), 67 bpm, and data from one sample is shown in Fig. 3.
59 bpm. Then, each sample (the parallel-based fusion of PPG, VPG, and APG
It can be seen that after the resampling process, this method does not signals) and its corresponding label (SBP and DBP) are assigned the same
change the waveform of the original signal, which not only retains the tag number. After repeating the above steps, a dataset containing the
physiological characteristics but also meets the input requirements of parallel-based fusion of PPG, VPG, and APG signals as input data and
the subsequent model. In addition, to overcome the time delay between SBP and DBP as labels are finally obtained in this study, which totally
the PPG signals and the BP signals, the average value of the five effective consisted of 100 patients and each patient has 1500 sets of input data
peak points and valley points of the BP signal which got through the and label. Then, the 150,000 samples processed in this study have been
same detection algorithm used on PPG signals [37] in each sample is randomly shuffled for the training and testing of the subsequent model.
used as the SBP and DBP respectively, that is, the label of the subsequent Correspondingly, the overall distribution of SBP and DBP is shown in
model. Fig. 4. It can be seen that the samples used in this study have covered
different BP situations, which basically meet the normal distribution in
2.1.3. Dataset setup both SBP and DBP.
To fully mine the potential information of raw time series PPG sig­ As shown in Table 1, the used dataset reach the requirement of the
nals, some researchers simultaneously used the first and second de­ AAMI standard for patient number. Besides, according to each patient’s
rivatives of PPG signals (i.e., VPG signals and APG signals) as
supplementary information without expanding other physiological sig­
nals. Moreover, these studies have been shown that the fusion of PPG
signals and the derivative signals not only can effectively provide the
dimension of input information, but also can improve the accuracy of
continuous BP prediction obviously [25,33]. However, the cascade-
based fusion of input signals used in these studies didn’t consider the
synchronization and relationship in the time domain, which hindered
the efficiency and effectiveness of information extraction. Therefore, in
order to address this problem, the parallel-based fusion of PPG, VPG and
APG signals is used as the input signals of the subsequent proposed
model for continuous BP monitoring in this research.
For each processed PPG signal segment including five cycles in
Section 2.1.2, the first derivative of the fitting function of the PPG signal
is obtained in this section, that is, the VPG function. Then 600 points are
taken within the original data length (5 cycles) according to the function
so that the VPG signal is obtained. Similarly, the APG signal is obtained
Fig. 4. SBP and DBP distribution of patients in our dataset.
by taking the second derivative of the fitting function of the PPG signal

Fig. 3. Example of the PPG, VPG and APG signal data from one sample.

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M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

Table 1 includes three modules: the basic network module, the attention
Requirements of subjects in the AAMI standard. mechanism module, and the residual mechanism module, which in­
No. of subjects Female ratio Male ratio volves the contracting path and the expansive path.
As is shown in Fig. 5, the contracting path (on the left side of the
AAMI >85 >30% >30%
Our dataset 100 37% 63% attention modules) successively consists of 8 residual modules, which
divide into five down-sampling blocks with the channel size of 64, 128,
256, 512, and 1024 respectively. In addition, instead of the 2 × 2 max-
ID, the gender information is searched from the database, and the pooling operation with stride 2 for down-sampling, the 3 × 1 convolu­
gender ratio of the used dataset is 63:37, which also meets the relevant tion operation with stride 2 is used for down-sampling between each
requirement of the AAMI standard. block to reduce the loss of key feature information. Motivated by that
different convolutional kernel sizes can increase the receptive field
2.2. Model building without loss of resolution and capture multi-scale key information, thus
after the last residual module in the contracting path, three parallel
2.2.1. Model designing convolution layers are set with kernel sizes of 1 × 1, 3 × 1, and 5 × 1 and
In this study, the ARIU model is designed to adaptively extract high- following with an attention module respectively.
dimensional features from input signals and effectively monitor In the expansive path, the output of three parallel attention modules
continuous BP (SBP and DBP values). The network structure of the is concatenated firstly by a convolution layer to achieve feature aggre­
designed model is shown in Fig. 5. gation. Besides, the expansive path mainly contains 12 convolutional
In this model, the parallel-based fusion of PPG, VPG, and APG signal layers, which are divided into five up-sampling blocks with the same
is taken as input with a size of 600 × 3, and the array of SBP and DBP is channel size as the contracting path. Moreover, an attention mechanism
taken as output with a size of 2 × 1. Moreover, this model mainly is embedded in each skip connection between the contracting path and

Fig. 5. Network structure of the ARIU model.

5
M. Yu et al.
the expansive path, that is, the feature set obtained adaptively before
each down-sampling in the contracting path is input into the attention
module, and then its output is fused with the same-scale adaptive fea­
tures set of the corresponding part in the expansive path. Through these
attention mechanism modules, the high and low dimensional adaptive
features obtained by the contracting and expansive path respectively can
be fully integrated, which effectively improves the multiscale repre­
sentation effectiveness of the extracted features. Finally, after a global
average pooling layer behind the expansive path, SBP and DBP are
respectively output through the fully connected layer.
2.2.1.1. Basic network module. As one of the typical structures of CNN,
the U-Net has achieved excellent performance in the field of medical
image segmentation [27], which has demonstrated the strong ability of
adaptive feature extraction and multi-scale feature learning and also has
great potential for monitoring continuous BP by using PPG signals.
Therefore, the basic network module of the proposed model is improved
based on the classic U-Net. For example, the channel size of the proposed
model is the same setting as the classic U-net [27]. Concretely, compared
to the original U-Net, the basic network module employed three parallel
convolution operations with different feature filters in the last layer of
the contracting path to obtain different receptive fields, which has
effectively achieved the multi-scale feature extraction through the
feature aggregation. In addition, the classical image-oriented U-Net
usually adopted the max-pooling layer to realize the downsampling
operation. But for the low-width time-series signals, the max-pooling
downsampling easily caused the loss of potential effective information
to some extent. To this end, the convolution operation with the small
feature kernel is replaced the original max-pooling layer. Therefore,
through these improvements on the classical U-Net, the basic network
module is employed to adaptively learn the high dimensional multi-
scale features from input signals.
2.2.1.2. Attention mechanism module. In the basic network module, the
convolution operations in both contracting and expansive path seam­
lessly integrate the spatial and channel information of the extracted
features on the different receptive fields, which obtained the richer and
more comprehensive multi-scale feature information. But the sensitivity
of this information to continuous BP monitoring is different, especially
for the multi-channel input signals of PPG, VPG, and APG signals, the
channel feature information is more important.
Through carrying out weighted learning on different feature chan­
nels, the squeeze and excitation (SE) module can effectively enhance
important feature information and suppress useless feature information
Fig. 6. Schematic diagram of the attention module structure.
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Biomedical Signal Processing and Control 75 (2022) 103581
[38]. Therefore, the attention mechanism based on the SE module was
embedded to the skip connections between the contracting and expan­
sive path, which was utilized to enhance the sensitivity of key multi-
scale features in the contracting path and reduce the information
fusion of redundant features across paths [30,31]. Concretely, the
attention mechanism structure proposed in this paper based on the SE
module [38] is shown in Fig. 6.
As is shown in Fig. 6, for the input feature maps with the size of L × C,
the attention mechanism module applied global average pooling-based
squeeze operations to aggregate the global information. In addition, to
take full advantage of the information, the exception operation is
employed to recalibrate the channel-wise feature responses adaptively
according to interdependencies between channels. Concretely, the
channel of aggregated features is firstly reduced from C to C/r through a
full connection layer in the exception operation. As a reduction ratio for
varying the module capacity, the parameter r is set to 4 in this study by
considering computation cost and model performance comprehensively.
Next, through the ReLU6 activation function layer shown as in formula 2
and a full connection layer, the amount of the channels is expanded from
C/r to C. Then, a hard-swish activation function layer is adopted to
replace the original sigmoid function layer, as shown in formula 3,
which further reduced the computation cost of the attention mechanism
module [39].
ReLU6 = min(6, max(0, x)) (2)
ReLU6(x + 3)
hard - swish [x] = x (3)
6
Finally, the recalibrated vector with a size of 1 × C is multiplied with
input features to obtain sensitive features with the size of L × C.
Consequently, by embedding the attention module in the skip connec­
tions of the basic network in this study, the proposed model reduced the
redundancy of features from input signals and learn the sensitive fea­
tures for adaptive BP monitoring.
2.2.2. Residual mechanism module
Although the attention mechanism can help the basic network
extract sensitive features from the input signals, with the increasing of
the convolution layers, the deep model confronted the vanishing
gradient and the performance degradation. Through the convolutional
mapping of skip connections, the residual network [40,41] can address
these problems and improve the ability of feature learning. Due to the
fact that the skip connections already existed in the expansive path of
the basic network, the residual module shown in Fig. 7 is only utilized to
replace the conventional convolution in the expansive path of the
M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

where N is the number of samples.

In this study, to train and evaluate the proposed model more effec­
tively, a 5-fold cross-validation method is used on a dataset that
randomly shuffles the 150,000 sets of data from 100 patients, which is
firstly divided into the training set, validating set, and testing set ac­
cording to the ratio of 7:1:2. Next, each training set is used to train the
model with the same loss function and optimizer. Finally, the testing set
is utilized to calculate the accuracy of BP monitoring, and the average of
the five results is regarded as the evaluating accuracy of the proposed
model for continuous BP monitoring. The cross-validation method is
shown in Fig. 8.

2.2.4. Model evaluation

In order to evaluate the performance of the proposed ARIU model for
monitoring continuous BP quantitatively, this study took mean absolute
error (MAE) and standard deviation (STD) as evaluating indicators.
The MAE is applied to measure the mean absolute error between the
actual BP value p and the estimated BP value ̂ p of the proposed model,
which the expression is as follows:
∑
N
MAE = p i |/N
|pi − ̂ (5)
i=1

where N is the number of samples.

The STD is applied to measure the standard deviation of absolute
error yi ≜|pi − ̂ p i |, which the expression is as follows:
√̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
√
√ 1 ∑ N
STD = √ (yi − y)2 (6)
N − 1 i=1

where y is the mean absolute error of the samples, and N is the

number of the samples.

3. Results and discussion

3.1. Environment setup

Fig. 7. Schematic diagram of residual module structure.
The deep model proposed in this paper is calculated by the frame­
work of Tensorflow 2.4.0 in Ubuntu 18.04 operating system and adopted
network proposed in this study.
CUDA10 to accelerate the calculation of GeForce RTX 3090 24G GPU.
Since the adaptive moment estimation (Adam) algorithm can adaptively
2.2.3. Model training
adjust the learning rate during the training process as well as make the
The mean square error (MSE) between the actual BP value p and the
model convergence faster simultaneously [42], this study uses Adam as
estimated BP value ̂ p of the proposed model is utilized as the loss
the gradient descent optimization algorithm to train the proposed
function to train the model proposed for continuous BP monitoring,
model. In addition, through the trial-and-error experiments, the initial
which is as follows:
learning rate is set as 10e-4, and the batch size and the training epoch
∑
N are set as 1024 and 500 respectively.
MSE = p i )2 /N
(pi − ̂ (4)
i=1

Fig. 8. Schematic diagram of 5-fold cross-validation method.

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M. Yu et al.
3.2. Ablation experiment and analysis
As shown in Fig. 5, based on the classic U-Net structure [27], the
proposed ARIU model is designed for continuous BP monitoring, which
mainly consists of three modules, namely an improved U-Net, an
attention module embedded in the skip connections, and a residual
module replaced common convolution. To test the effectiveness of each
module, ablation experiments are conducted on the used dataset.
Firstly, based on the classic U-Net model, Model A is designed as the
basic reference model in the ablation experiment. Then, on the basis of
Model A, we modified the model step by step by optimizing the down-
sampling layer, adding a new multi-scale feature extraction layer,
attention modules, and residual modules. Concretely, the description of
each ablation model is described in Table 2, and the details of the
improvement can be referred to in Section 2.2.1. In addition, the sepa­
rate PPG signals, the cascade-based fusion of the PPG, VPG, and APG
signals (PPG + VPG + APG), and the parallel-based fusion of the PPG,
VPG, and APG signals (PPG & VPG & APG) are used as input for training
the different models respectively.
In the ablation experiment, a five-fold cross-validation method is
used to train each model described in Table 2. In the training and vali­
dating process, the change curves of MAE of SBP and DBP under the
different models are drawn in Fig. 9 and Fig. 10 respectively. It can be
seen that the classic U-Net structure (Model A) converges faster
benefiting from fewer total parameters, but the proposed model has
higher accuracy when the model converges. Besides, although the input
form of “PPG + VPG + APG” increases the amount of information, the
monitoring effects of Model A, Model B, and Model C deteriorate obvi­
ously without considering the time-series correlation among PPG, VPG,
and APG.
Finally, the average results of two measurement criteria on the
testing sets are shown in Table 3 below.
As can be seen from Table 3, the MAE and STD of SBP predicted by
the proposed model are 4.75 mmHg and 6.72 mmHg respectively, which
are the minimum values in all ablation models under different inputs.
Meanwhile, the MAE and STD of DBP predicted by the proposed model
are 2.81 mmHg and 4.59 mmHg respectively, which are also the mini­
mum values in all ablation models under different inputs. These results
show that the proposed model can effectively improve the accuracy of
continuous BP monitoring.
The superiorities of both the model network and the input forms
proposed in this research are effectively verified by the ablation exper­
iments. On the one hand, from the perspective of the model structure,
the predicted errors of the proposed model under three input forms are
not only smaller than the basic U-Net model, but also as a whole smaller
than other ablation models. On the other hand, from the perspective of
the input form, the predicted errors of the parallel-based “PPG & VPG &
APG” signals under five ablation models are not only smaller than the
separate PPG signals but also as a whole smaller than the cascade-based
Table 2
The description of the models for ablation experiment.
Model Description
Model A Classic U-Net [27]: imitate the model designed by the U-net
proponent, including structure, parameters, and dimensions.
Model B Improved U-Net: optimized the down-sampling layer and added a
new multi-scale feature extraction layer in the contracting path
based on Model A.
Model C Model B integrated the residual mechanism: replaced the conventional
convolution modules with the residual modules in the contracting
path based on Model B.
Model D Model B integrated the attention mechanism: embedded the attention
module in the skip connections and the multi-scale feature
extraction layer based on Model B.
Proposed Model B integrated the attention mechanism and the residual
Model mechanism simultaneously: the details are described in Section 2.2.1
Model designing.
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Biomedical Signal Processing and Control 75 (2022) 103581
“PPG + VPG + APG” signals.
3.3. Comparative experiment and analysis
To further demonstrate the effectiveness and advancement of the
proposed model, the comparative experiment is implemented with the
existing state-of-art models in the publicized literature. Concretely, the
details of these compared models are described in Table 4.
Since the fact that these studies have used different datasets or
different numbers of objects for BP monitoring, thus fair comparison
can’t be performed for BP measurement. To eliminate the impact of the
object and database capacity, the comparisons of these models are car­
ried out on the same datasets used in this study by using the 5-fold cross-
validation. Finally, the results of the different models are shown in
Table 5.
It can be seen from Table 5, both MAE and STD of the SBP and DBP
predicted by the proposed model are obviously lower than other
compared models obviously, which means that the proposed model in
this paper has higher accuracy for BP monitoring. In addition, the scatter
diagram of the predicted values of SBP and DBP relative to the actual
values are presented in Fig. 11 and Fig. 12 respectively.
It can be seen intuitively that, whether for SBP or DBP, the predicted
values of the proposed model are closer to the actual values. As shown in
Fig. 11 and Fig. 12, the Pearson correlation coefficient of SBP and DBP
predicted by the model proposed in this paper are 0.932 and 0.905
respectively, which demonstrated that the proposed model has a better
performance.
The error distributions of the SBP and DBP predicted by each model
are presented in Fig. 13 and Fig. 14 respectively. According to the dis­
tribution histograms, it is obviously found that compared with other
models, the error distribution of the proposed model is significantly
more concentrated and closer to zero. In addition, to quantitatively
analyze the error distribution of these models, the percentage of samples
that the predicted error between + 5 mmHg and − 5 mmHg are shown in
the upper-left of these figures. It can be seen that the proposed model has
more small error samples in predicting BP. Therefore, these results
further demonstrated that the proposed model can more accurately
monitor continuous BP.
Furthermore, the Bland-Altman analysis is carried out for the pro­
posed model, and the analysis results are drawn in Fig. 15.
As is shown in Fig. 15, it can be found that 94.95% of samples are
within the consistency boundary for SBP, and 95.77% of samples are
within the consistency boundary for DBP. The results show that the
predicted BP values of the proposed model are in good agreement with
the actual BP value.
3.4. Verification with international standards
To verify the practical significance of the proposed model, the pre­
dicted results are compared with two internationally recognized
sphygmomanometer standards, namely AAMI [45] and BHS [46]. The
result of this comparison means whether the method of this research has
the ability to meet the error requirements of these standards in the
actual application of the measurement process. Especially for contin­
uous BP monitoring, every real-time calculation needs to meet this error
requirement.
AAMI standard is used for non-invasive BP monitoring, which mainly
includes the number of subjects, MAE, and STD criteria. The standard
requires MAE and STD to be less than 5 mmHg and 8 mmHg respec­
tively. As is shown in Table 6, for the proposed model, the MAE of SBP
and DBP are 4.75 mmHg and 2.81 mmHg respectively, and the STD of
SBP and DBP are 6.72 and 4.69 respectively, which all of them are
satisfied with the requirements of the AAMI standard.
BHC standard takes the percentage of the samples within three
different error thresholds as the evaluation standard. The standard has
three grades with A/B/C, and each grade has three thresholds with 5/
M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

Fig. 9. Diagrams of the training and validation curves for SBP under different ablation models.

Fig. 10. Diagrams of the training and validation curves for DBP under different ablation models.

10/15 mmHg. As is shown in Table 7, both SBP and DBP predicted by the study passed the standard except for the proposed model. Therefore,
proposed model are achieved Grade A within all three thresholds. verified with the requirements of AAMI and BHS standards, it can be
It is worth noting that none of the other comparative models in this found that the model proposed in this paper has excellent performance

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M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

Table 3
Performances of the ablation models under different inputs.
Model PPG PPG + VPG + APG PPG & VPG & APG

SBP/mmHg DBP/mmHg SBP/mmHg DBP/mmHg SBP/mmHg DBP/mmHg

MAE STD MAE STD MAE STD MAE STD MAE STD MAE STD

Model A 6.65 7.58 4.51 5.77 6.46 7.31 3.89 5.12 6.29 7.02 3.77 4.93
Model B 6.36 7.51 3.75 5.20 6.33 7.24 3.67 4.98 6.29 7.43 3.67 5.07
Model C 6.29 7.44 3.69 5.08 6.31 7.36 3.63 4.95 6.27 7.49 3.67 5.10
Model D 5.23 7.26 3.08 4.97 5.29 7.30 3.07 4.98 5.00 6.95 2.95 4.86
ProposedModel 4.91 6.87 2.91 4.85 5.16 7.13 3.04 5.05 4.75 6.72 2.81 4.59

can improve the predicting accuracy of SBP and DBP certainly. In gen­
Table 4
eral, the results of the ablation and comparison experiments and the
The description of the models for comparison experiment.
significance test demonstrate the effectiveness and improvement of the
Model Descriptions proposed model and the advancement of the designed structure and the
Model 1 Spectro-Temporal Deep Neural Network: Deep residual network fused input form.
model based on time–frequency domain information fusion [25]. Next, a significance test is performed between the proposed model
Model 2 PP-Net Model: Deep network model combined CNN with LSTM
and other advanced models, and the results are shown in Table 9.
[43].
Model 3 ResNet18: Classic deep residual network [40]. Analyzing the results of significant experiments, it can be seen that the
Model 4 Deep network model based on CNN, Bi-GRU, and attention module proposed model has a very significant difference compared with other
[44]. comparative models. Combining the results in Table 5, it can be
Model 5 U-Net deep learning model: Classic U-Net modified with Leaky ReLU concluded that the model proposed in this study has obvious
activation function, dropout layer, convolution layer in expansion
advantages.
path [28].
Proposed Improved U-Net integrated attention mechanism module and Finally, according to the comparison between the monitoring results
Model residual mechanism module. of the proposed model and the AAMI and BHS standards in Table 6 and
Table 7, the proposed model has practical application potential in the
current wearable smart device field. And it also provides new ideas for
Table 5 other researchers in terms of model structure design and data input form
Comparison results of the different models. to some extent.
Model SBP/mmHg DBP/mmHg
Since the dataset used in this study is limited, the model is not
lightweight enough, and there is still a great potential for optimization.
MAE STD MAE STD
In future work, on the one hand, we will increase the capacity of data to
Model 1 12.23 10.67 8.64 7.69 enhance the generalization ability of the model. On the other hand, try
Model 2 9.29 5.97 9.31 6.28 to reduce the model parameter to decrease computing resource
Model 3 8.09 8.20 4.99 5.66
Model 4 7.56 8.11 4.56 5.47
consumption.
Model 5 6.58 7.22 4.08 5.05
Proposed Model 4.75 6.72 2.81 4.59 4. Conclusion

This paper proposes an ARIU model for continuous BP monitoring. In

and reliability.
3.5. Discussion and future work
In this study, the effectiveness and advancement of the proposed
model are verified on the MIMIC-III dataset by the ablation and com­
parison experiments. Furthermore, to eliminate the interference of the
randomness and limitation of the experiment, a significant test on the
monitoring data is performed to determine whether the difference of
each model is caused by accidental factors or errors, or whether there
are indeed differences between these models.
According to the characteristics of the experiment, the method of
paired samples t-test is used to test the significance of the prediction
error of SBP and DBP in the experimental results. The results of paired
samples t-test among ablation models are shown in Table 8, where α
represents the model using the input form of “PPG & VPG & APG”, β
represents the model using the input form of “PPG + VPG + APG”, and γ
represents the model using the input form of PPG.
It can be seen from Table 8 that the proposed model has a significant
difference from other models. In terms of network structure, compared
with other ablation models, the P-value of the SBP/DBP prediction error
of the proposed model is less than the significance level (0.05), which
means there is a very significant difference between these models. In
addition, through the results among the proposed model of different
input forms, it is also found that there are significant differences. The
results indicate the parallel-based fusion form of “PPG & VPG & APG”
this model, the parallel-based fusion of PPG, VPG, and APG signals is
directly utilized as input to estimate BP, then the improved U-Net was
employed to adaptively extract multi-scale features, the attention
module is embedded in the skip connections to automatically restrain
redundant information, and the residual module is adopted to replace
common convolution to enhance the generalization capability.
The proposed model is validated by the ablation and comparison
experiments on the public MIMIC-III dataset. The experimental results
-show that the accuracy of the model proposed in this paper is higher
than other state-of-art methods, which meets the requirements of the
AAMI standard and reaches the “Grade A” standard of BHS. Therefore,
this paper provides a new perspective for continuous BP monitoring by
directly using PPG signals and can be easily employed to deal with cuff-
less BP measurement at a low-cost and high-precision.
CRediT authorship contribution statement
Mingzheng Yu: Methodology, Software, Data curation, Writing –
original draft, Writing – review & editing. Zhiwen Huang: Investiga­
tion, Validation, Formal analysis, Writing – original draft, Writing –
review & editing. Yidan Zhu: Visualization, Investigation, Formal
analysis. Panyu Zhou: Conceptualization, Supervision, Investigation.
Jianmin Zhu: Supervision, Project administration, Funding acquisition,
Writing – review & editing.

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M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

Fig. 11. Diagram of the correlation analysis between the predicted and actual SBP.

Fig. 12. Diagrams of the correlation analysis between the predicted and actual DBP.

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M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

Fig. 13. Error distribution histograms of the predicted SBP under different models.

Fig. 14. Error distribution histograms of the predicted DBP under different models.

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M. Yu et al. Biomedical Signal Processing and Control 75 (2022) 103581

Fig. 15. Bland-Altman plots for SBP (left) and DBP (right).

Declaration of Competing Interest

Table 6
Performance comparison with AAMI standard.
The authors declare that they have no known competing financial
MAE (mmHg) STD (mmHg) interests or personal relationships that could have appeared to influence
AAMI BP ≤5.00 ≤8.00 the work reported in this paper.
Proposed model SBP 4.75 6.72
DBP 2.81 4.59
Acknowledgment

This research was financially supported by grants from the National

Table 7 Natural Science Foundation of China (No. 51775323), and the Inter­
Performance comparison with BHS standard.
disciplinary program of the University of Shanghai for Science and
Cumulative Error (%) Technology (No.10-20-304-402). Our deepest gratitude goes to the
BHS ≤5 mmHg ≤10 mmHg ≤15 mmHg anonymous reviewers for their careful work and thoughtful suggestions
Grade A 60% 85% 95% that have helped improve this paper substantially.
Grade B 50% 75% 90%
Grade C 40% 65% 85%
Proposed model SBP 72% 89.4% 95% References
DBP 86.3% 95.4% 97.9%
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