Myocardial oxygen supply and demand imbalance predicts mortality in older nursing home residents: The PARTAGE study.

BACKGROUND: A mismatch between myocardial oxygen supply and demand is the most common cause of ischemic myocardial injury in older persons. The subendocardial viability ratio (SEVR) can usefully estimate the degree of myocardial perfusion relative to left-ventricular workload. The aim of the present study was to evaluate the ability of SEVR to predict long-term mortality in the older population. Additionally, we aimed to identify the SEVR cutoff value best predicting total mortality. METHODS: This is a multicenter, longitudinal study involving a large population of individuals older than 80 years living in nursing homes. Patients with cancer, severe dementia, and very low level of autonomy were excluded from the study. Participants were monitored for 10 years. Adverse outcomes were recorded every 3 months from inclusion to the end of the study. SEVR reflects the balance between subendocardial oxygen supply and demand, and was estimated non-invasively by analyzing the carotid pressure waveform recorded by applanation arterial tonometry. RESULTS: A total of 828 people were enrolled (mean age: 87.7 ± 4.7 years, 78% female). 735 patients died within 10 years and 24 were lost to follow-up. SEVR was inversely associated with mortality at univariate Cox-regression model (risk ratio, 0.683 per unit increase in SEVR; 95% confidence interval (CI) [0.502-0.930], p = 0.015) and in a model including age, sex, body mass index, Activity of Daily Living index and Mini-Mental State Examination score (risk ratio, 0.647; 95% CI [0.472-0.930]). The lowest tertile of SEVR was associated with higher 10-years total mortality than the middle (p < 0.001) and the highest (p < 0.004) tertile. A SEVR cutoff value of 83% was identified as the best predictor of total mortality. CONCLUSIONS: SEVR may be considered as a marker of "cardiovascular frailty." An accurate non-invasive estimation of SEVR could be a useful and independent parameter to assess survival probability in very old adults. TRIAL REGISTRATION: NCT00901355, registered on ClinicalTrials.gov website.

2024 Recommendations for Validation of Noninvasive Arterial Pulse Wave Velocity Measurement Devices.

BACKGROUND: Arterial stiffness, as measured by arterial pulse wave velocity (PWV), is an established biomarker for cardiovascular risk and target-organ damage in individuals with hypertension. With the emergence of new devices for assessing PWV, it has become evident that some of these devices yield results that display significant discrepancies compared with previous devices. This discrepancy underscores the importance of comprehensive validation procedures and the need for international recommendations. METHODS: A stepwise approach utilizing the modified Delphi technique, with the involvement of key scientific societies dedicated to arterial stiffness research worldwide, was adopted to formulate, through a multidisciplinary vision, a shared approach to the validation of noninvasive arterial PWV measurement devices. RESULTS: A set of recommendations has been developed, which aim to provide guidance to clinicians, researchers, and device manufacturers regarding the validation of new PWV measurement devices. The intention behind these recommendations is to ensure that the validation process can be conducted in a rigorous and consistent manner and to promote standardization and harmonization among PWV devices, thereby facilitating their widespread adoption in clinical practice. CONCLUSIONS: It is hoped that these recommendations will encourage both users and developers of PWV measurement devices to critically evaluate and validate their technologies, ultimately leading to improved consistency and comparability of results. This, in turn, will enhance the clinical utility of PWV as a valuable tool for assessing arterial stiffness and informing cardiovascular risk stratification and management in individuals with hypertension.

Interaction of large artery stiffness and baroreceptor function explored through multiple measurement techniques - a pilot study.

Baroreceptors, sensors that play a role in controlling arterial blood pressure (BP), are mechanical stretch receptors located in the aortic arch and carotid sinuses. Factors affecting the degree of stretch in the vessel wall with BP, such as increased arterial stiffness, may compromise baroreceptor sensitivity (BRS) to BP changes. Yet, evidence of this is scattered, as both baroreceptor sensitivity (BRS) and arterial stiffness are calculated variables with multiple methodological approaches. This pilot study (n=10) investigates the correlation of arterial stiffness and BRS using multiple BRS calculation techniques (spectral and sequence methodologies at aortic and finger sites) and arterial stiffness measurement [carotid-femoral pulse wave velocity (cfPWV), carotid compliance and distensibility]. BRS was assessed under resting BP conditions and during BP altered by maneuvers (0.1 Hz controlled breathing and leg ischemia). Magnitude of arterial stiffness - BRS correlation was positive for carotid distensibility and compliance, and negative for cfPWV, supporting the theory. A sample size of 100 participants (not rounded - exact figure by power calculation) would be required to confirm or reject all permutations of correlation between BRS by multiple calculation methods and large artery stiffness by PWV and compliance/distensibility measures.

From peripheral finger-derived pulse waveforms to aortic pressure waveform features: an application of a generalized transfer function.

OBJECTIVE: Aortic (central) pressure features are associated with cardiovascular complications and can be algorithmically derived from non-invasive peripheral arterial waveforms. This has conventionally been performed with a pressure waveform (i.e., tonometry or oscillometry) rather than with the optical-based sensor (photoplethysmography (PPG)) that is predominantly used in wearable health devices. Extraction of aortic features from a peripheral PPG waveform has yet to be investigated. This study aims to compare aortic features extracted from peripheral arterial waveforms acquired with different sensor modalities using the same transfer function. DESIGN AND METHOD: Radial tonometry (reference), finger volume-clamped PPG (Penáz) and fingertip PPG waveforms were measured in participants (n=29, 36±16 years, 15 female) under baseline conditions. Waveforms were converted into an aortic pressure waveform using the transfer function. Waveform features were extracted from the converted waveform. Extracted features were compared with correlation plots and a Bland-Altman analysis. RESULTS: Aortic pressure features extracted from a finger using the Penáz technique were comparable to radial tonometry derived features. Aortic features extracted from a fingertip waveform were more variable in comparison to radial tonometry-derived features. CONCLUSIONS: Aortic (central) pressure waveform features contain valuable haemodynamic information and have the capacity to be easily and conveniently implemented in wearable health devices. Future use of these features in wearable health devices incorporating PPG requires the development, and/or, optimization of a unique transfer function to more accurately represent the aortic pressure waveform for cardiovascular assessment.Clinical Relevance- Aortic pressure features might be used in wearable health devices following the development of a unique transfer function for optical-transduced peripheral vascular signals.

Comparison of effects of peripheral vasculature on tonometric radial pulse and cuff-based brachial pulse waveform as used in estimation of central aortic pressures.

OBJECTIVE: Aortic pressure estimation requires reliable peripheral pulse waveform acquisition. The peripheral waveform can change with local vascular effects that can be independent of aortic pressure. This study quantifies the effects of peripheral vasculature changes on radial and brachial waveforms. DESIGN AND METHOD: In 20 subjects (37± 15 years, 7 female), brachial volumetric displacement (cuff-based) and radial tonometry waveforms were simultaneously measured whilst a cuff around the hand on the same arm was inflated to induce transmural pressures of -60, -30, -15, 0, 15 and 30 mmHg, altering local peripheral resistance and compliance by graded arterial wall unloading. Aortic blood pressure (BP), augmentation index (AIx) and ejection duration were calculated from the measurements using a generalized transfer function. The parameters under unloaded conditions were compared to baseline measurements. RESULTS: Brachial systolic and diastolic BP did not change throughout the experiment. Altering peripheral resistance and compliance did not significantly change calculated aortic BP values, although changes were nominally greater for radial (maximum +8±1 mmHg) compared to brachial (maximum +2±1 mmHg) waveforms. AIx at 0 mmHg transmural pressure (maximum arterial wall unloading) was higher when derived from radial waveforms (+24±3%, p<0.001) but not when derived from brachial waveforms. CONCLUSIONS: Localized changes in peripheral resistance and compliance affect tonometer acquired radial waveforms but not volumetric displacement acquired brachial pressure waveforms, as judged by computed central aortic augmentation pressure parameters. This suggests aortic pressure estimation from the brachial cuff waveform is less sensitive to peripheral vasculature disturbances that alter the peripheral arterial pulse morphology.

Bilateral cuff-induced lower limb post-ischemia hyperemia as a method for acute reduction in blood pressure for cuffless blood pressure device testing.

OBJECTIVE: Development and testing of cuffless blood pressure (BP) devices requires methods to increase and decrease BP. This is also required by cuffless BP validation standards. Pharmacological interventions, whilst successful, are not always feasible for all subpopulations or research settings. Non-pharmacological approaches for increasing BP are available, however, methods for decreasing BP are not well described. This study investigates the hyperemic response following bilateral leg-cuff ischemia as a method for acute BP lowering. DESIGN AND METHOD: Participants (n=8, 24±8 years, 6 female) had their BP measured by continuous (finger, Penáz technique) and intermittent (brachial cuff, oscillometric) methods before, during and following 3-minute leg-ischemia with the participant in an upright position. Total peripheral resistance (TPR) and cardiac output (CO) were calculated from finger BP waveforms. Maxima and minima responses in the variables were extracted and compared to resting conditions by repeated measures analysis of covariance. RESULTS: During the hyperemic period, systolic BP decreased by -22±3 mmHg (finger) and -6±1 mmHg (brachial). Diastolic BP decreased by -14±5 mmHg (finger) and -4 ±1 mmHg (brachial). Calculated TPR and CO varied, with both decreasing by half and almost doubling during the hyperemic response period. CONCLUSIONS: Leg-cuff ischemia provides a controlled, non-pharmacological intervention for decreasing systemic arterial BP. This removes some of the limitations in testing, development and validation of cuffless BP techniques and devices.

European Society of Hypertension recommendations for the validation of cuffless blood pressure measuring devices: European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability.

BACKGROUND: There is intense effort to develop cuffless blood pressure (BP) measuring devices, and several are already on the market claiming that they provide accurate measurements. These devices are heterogeneous in measurement principle, intended use, functions, and calibration, and have special accuracy issues requiring different validation than classic cuff BP monitors. To date, there are no generally accepted protocols for their validation to ensure adequate accuracy for clinical use. OBJECTIVE: This statement by the European Society of Hypertension (ESH) Working Group on BP Monitoring and Cardiovascular Variability recommends procedures for validating intermittent cuffless BP devices (providing measurements every >30 sec and usually 30-60 min, or upon user initiation), which are most common. VALIDATION PROCEDURES: Six validation tests are defined for evaluating different aspects of intermittent cuffless devices: static test (absolute BP accuracy); device position test (hydrostatic pressure effect robustness); treatment test (BP decrease accuracy); awake/asleep test (BP change accuracy); exercise test (BP increase accuracy); and recalibration test (cuff calibration stability over time). Not all these tests are required for a given device. The necessary tests depend on whether the device requires individual user calibration, measures automatically or manually, and takes measurements in more than one position. CONCLUSION: The validation of cuffless BP devices is complex and needs to be tailored according to their functions and calibration. These ESH recommendations present specific, clinically meaningful, and pragmatic validation procedures for different types of intermittent cuffless devices to ensure that only accurate devices will be used in the evaluation and management of hypertension.

Personalized aortic pressure waveform estimation from brachial pressure waveform using an adaptive transfer function.

BACKGROUND AND OBJECTIVE: The aortic pressure waveform (APW) provides reliable information for the diagnosis of cardiovascular disease. APW is often measured using a generalized transfer function (GTF) applied to the peripheral pressure waveform acquired noninvasively, to avoid the significant risks of invasive APW acquisition. However, the GTF ignores various physiological conditions, which affects the accuracy of the estimated APW. To solve this problem, this study utilized an adaptive transfer function (ATF) combined with a tube-load model to achieve personalized and accurate estimation of APW from the brachial pressure waveform (BPW). METHODS: The proposed method was validated using APWs and BPWs from 34 patients. The ATF was defined using a tube-load model in which pulse transit time and reflection coefficients were determined from, respectively, the diastolic-exponential-pressure-decay of the APW and a piece-wise constant approximation. The root-mean-square-error of overall morphology, mean absolute errors of common hemodynamic indices (systolic blood pressure, diastolic blood pressure and pulse pressure) were used to evaluate the ATF. RESULTS: The proposed ATF performed better in estimating diastolic blood pressure and pulse pressure (1.63 versus 1.94 mmHg, and 2.37 versus 3.10 mmHg, respectively, both P < 0.10), and produced similar errors in overall morphology and systolic blood pressure (3.91 versus 4.24 mmHg, and 2.83 versus 2.91 mmHg, respectively, both P > 0.10) compared to GTF. CONCLUSION: Unlike the GTF which uses fixed parameters trained on existing clinical datasets, the proposed method can achieve personalized estimation of APW. Hence, it provides accurate pulsatile hemodynamic measures for the evaluation of cardiovascular function.

The Microsoft Research Aurora Project: Important Findings on Cuffless Blood Pressure Measurement.

Conventional blood pressure (BP) measurement devices based on an inflatable cuff only provide a narrow view of the continuous BP profile. Cuffless BP measuring technologies could permit numerous BP readings throughout daily life and thereby considerably improve the assessment and management of hypertension. Several wearable cuffless BP devices based on pulse wave analysis (applied to a photoplethysmography or tonometry waveform) with or without use of pulse arrival time are now available on the market. The key question is: Can these devices provide accurate measurement of BP? Microsoft Research recently published a complex article describing perhaps the most important and highest resource project to date (Aurora Project) on assessing the accuracy of several pulse wave analysis and pulse wave analysis-pulse arrival time devices. The overall results from 1125 participants were clear-cut negative. The present article motivates and describes emerging cuffless BP devices and then summarizes the Aurora Project. The study methodology and findings are next discussed in the context of regulatory-cleared devices, physiology, and related studies, and the study strengths and limitations are pinpointed thereafter. Finally, the implications of the Aurora Project are briefly stated and recommendations for future work are offered to finally realize the considerable potential of cuffless BP measurement in health care.

Cuffless Blood Pressure Measurement.

Cuffless blood pressure (BP) measurement has become a popular field due to clinical need and technological opportunity. However, no method has been broadly accepted hitherto. The objective of this review is to accelerate progress in the development and application of cuffless BP measurement methods. We begin by describing the principles of conventional BP measurement, outstanding hypertension/hypotension problems that could be addressed with cuffless methods, and recent technological advances, including smartphone proliferation and wearable sensing, that are driving the field. We then present all major cuffless methods under investigation, including their current evidence. Our presentation includes calibrated methods (i.e., pulse transit time, pulse wave analysis, and facial video processing) and uncalibrated methods (i.e., cuffless oscillometry, ultrasound, and volume control). The calibrated methods can offer convenience advantages, whereas the uncalibrated methods do not require periodic cuff device usage or demographic inputs. We conclude by summarizing the field and highlighting potentially useful future research directions.

Association between Brachial-Ankle Pulse Wave Velocity as a Marker of Arterial Stiffness and Body Mass Index in a Chinese Population.

Objectives: Arterial stiffness is widely accepted as an important predictor of cardiovascular disease (CVD) development. While obesity is generally associated with increased CVD risk, there is evidence that overweight patients with existing CVD may have better clinical outcomes than their lean counterparts. Our study sought to observe any potential association between brachial−ankle pulse wave velocity (BAPWV), a marker of arterial stiffness related to CVD risk, and Body Mass Index (BMI), a crude and widely used measure of obesity. Methods: Adult individuals (n = 857) assessed for routine CV risk were included and grouped according to their BMI (<25 kg/m2: normal; 25−30 kg/m2: overweight, ≥30 kg/m2: obese). Their anthropometric parameters, brachial cuff pressures, and BAPWV were measured. Results: Brachial pressure was significantly higher as BMI increased. BAPWV showed a positive linear association with systolic (r = 0.66, p < 0.01), mean (r = 0.60, p < 0.01), diastolic (r = 0.51, p < 0.01), and pulse (r = 0.53, p < 0.01) pressures. However, a linear relationship between BMI and BAPWV was only apparent in males aged <50 years (p = 0.01) and in females aged ≥50 years (p < 0.01). In individuals with similar brachial systolic pressure, BAPWV was higher in normal-weight subjects compared to overweight−obese ones. Conclusions: This conflicting finding is attributed to an overestimation of the degree of arterial stiffness as a measure of CVD risk in individuals with a less 'healthy' BMI. This suggests that BMI may not the appropriate obesity indicator to assess CV risk. Our finding emphasizes the importance of establishing a non-linear relationship between CVD risk, age, and BMI, taking into account apparent sex differences, to predict future CV events. While this finding may suggest a lower degree of stiffness in large arteries of overweight−obese subjects compared to their normal-weight counterparts, the potential implications for individuals with higher BMI need be explored further.

Estimation of cardiac stroke volume from radial pulse waveform by artificial neural network.

BACKGROUND AND OBJECTIVES: Stroke volume (SV) and cardiac output (CO) are the key indicators for the evaluation of cardiac function and hemodynamic status during the perioperative period, which are very important in the detection and treatment of cardiovascular diseases. Traditional CO and SV measurement methods have problems such as complex operation, low precision and poor generalization ability. METHODS: In this paper, a method for estimating stroke volume based on cascade artificial neural network (ANN) and time domain features of radial pulse waveform (SVANN) was proposed. The simulation datasets of 4000 radial pulse waveforms and stroke volume (SVmeas) were generated by a 55 segment transmission line model of the human systemic vasculature and a recursive algorithm. The ANN was trained and tested by 10-fold cross-validation, and compared with 12 traditional models. RESULTS: Experimental results showed that the Pearson correlation coefficients and mean difference between SVANN and SVmeas (R=0.95, mean standard deviation (SD) = 0.00 ± 6.45) were better than the best results of the 12 traditional models. Moreover, as increasing the number of training samples, the performance improvement of the ANN (R=0.94(Δ + 0.04), mean ± SD = 0.00 ± 6.38(Δ± 2.02)) was better than the other best model, namely, multiple linear regression model (MLR) (R=0.93(Δ + 0.03), mean ± SD = 0.00 ± 6.99(Δ± 1.50)). CONCLUSIONS: A method is proposed to estimate cardiac stroke volume by the ANN with time domain features of radial pulse wave. It avoids the complicated modeling process based on hemodynamics within traditional models, improves the estimation accuracy of SV, and has a good generalization ability.

The prevalence and impact of orthostatic intolerance in young women across the hypermobility spectrum.

Orthostatic intolerance (OI) is frequently reported in young women with generalized hypermobility spectrum disorder (G-HSD) and hypermobile EDS (hEDS). However, it remains currently unclear whether OI is a comorbidity or fundamental part of the pathophysiology of G-HSD or hEDS. This study investigated the prevalence and impact of OI in young women across the hypermobility spectrum. Forty-five women (14-30 years, 15 controls, 15 G-HSD, and 15 hEDS) undertook a head-up tilt (HUT) and active stand test. Postural Orthostatic Tachycardia Syndrome (POTS) and Orthostatic Hypotension (OH) were assessed using age-related criteria. Autonomic dysfunction and quality-of-life questionnaires were also completed. The prevalence of POTS was higher in women with G-HSD than hEDS and control groups during HUT (43% vs. 7% and 7%, respectively, p < 0.05), but similar between groups during the active stand (47%, 27%, and 13% for G-HSD, hEDS, and control, respectively). No participants had OH. hEDS and G-HSD participants reported more severe orthostatic symptoms and poorer quality of life than controls. Although POTS was observed in hypermobile participants, there is no conclusive evidence that its prevalence differed between groups due to differences between the HUT and active stand assessments. Nevertheless, OI and broader autonomic dysfunction impacted on their quality of life.

Relationship between heart rate and central aortic blood pressure: implications for assessment and treatment of isolated systolic hypertension in the young.

Isolated systolic hypertension in the young (ISHY) remains a challenging problem, partly due to the differences in central aortic pressure observed in studies investigating ISHY. The fundamental relationship between heart rate and central aortic pressure, and more precisely, the relationship between heart rate and amplification of central aortic pressure in the periphery, underpins the assessment and, as a consequence, the treatment of ISHY. Physiology warrants that an increase in heart rate would lead to increased amplification of the pressure pulse between the aorta and the brachial artery. Heart rate generally decreases with age, in particular over the first two decades of life. Thus, a higher heart rate in the young would result in higher pulse pressure amplification, and therefore an elevated brachial systolic pressure would not necessarily translate to elevated aortic systolic pressure. However, elevated heart rate is not a consistent feature in ISHY, and studies have shown that ISHY can present with either high or low central aortic systolic pressure. In this brief review, we summarize the physiological aspects underlying the relationship between heart rate and central aortic blood pressure and its amplification in the brachial artery, how this relationship changes with age, and examine the implications of these effects on the assessment and treatment of ISHY.

Expert Consensus on the Clinical Use of Pulse Wave Velocity in Asia.

Arterial stiffness is a progressive aging process that predicts cardiovascular disease. Pulse wave velocity (PWV) has emerged as a noninvasive, valid, and reliable measure of arterial stiffness and an independent risk predictor for adverse outcomes. However, up to now, PWV measurement has mostly been used as a tool for risk prediction and has not been widely used in clinical practice. This consensus paper aims to discuss multiple PWV measurements currently available in Asia and to provide evidence-based assessment together with recommendations on the clinical use of PWV. For the methodology, PWV measurement including the central elastic artery is essential and measurements including both the central elastic and peripheral muscular arteries, such as brachial-ankle PWV and cardio-ankle vascular index, can be a good alternative. As Asian populations are rapidly aging, timely detection and intervention of "early vascular aging" in terms of abnormally high PWV values are recommended. More evidence is needed to determine if a PWV-guided therapeutic approach will be beneficial to the prevention of cardiovascular diseases beyond current strategies. Large-scale randomized controlled intervention studies are needed to guide clinicians.

Contactless video-based photoplethysmography technique comparison investigating pulse transit time estimation of arterial blood pressure.

BACKGROUND: Non-contact measurement of physiological vital signs, such as blood pressure (BP), by video-based photoplethysmography (vPPG) is a potential means for remote health monitoring. However, the signal-to-noise ratio of cardiovascular signals within the vPPG is very low. OBJECTIVE: This study investigates the potential of BP estimation from vPPG. METHODS: In 10 healthy volunteers (4 females, 28 ± 7 years), continuous electrocardiogram, finger BP and video of the face and palm of the hand were recorded. BP was varied by isometric hand grip exercise and leg ischemia. Four vPPG methods were compared: (i) averages of the green (GREEN) color intensity; (ii) the best linear combination of color channels using independent component analysis (ICA); (iii) a linear combination of chrominance-based (CHROM) signal by standardizing the skin color profile; (iv) plane orthogonal to the skin tone (POS) as vPPG signal. These were applied to 14 regions of interest (ROIs) on the face and 5 ROIs on the palm. Pulse transit time (PTT) between ROIs, for all permutations, were calculated and the correlation with BP quantified. RESULTS: A significant, negative PTT-BP correlation was defined as success. A maximum success rate of 80% was achieved, occurring for the GREEN, POS and ICA methods only for specific ROIs within the face, but not for any permutation using the hand. CONCLUSIONS: These results indicate that the use of vPPG for estimation of BP will be challenging. A combination of different vPPG methods and within-face ROIs may yield useful information.

Blood pressure-independent neurogenic effect on conductance and resistance vessels: a consideration for cuffless blood pressure measurement?

BACKGROUND: Pulse transit time (PTT) and pulse arrival time (PAT) are promising measures for cuffless arterial blood pressure (BP) estimation given the intrinsic arterial stiffness-BP relationship. However, arterial stiffness (and PTT) is altered by autonomically-driven smooth muscle tension changes, potentially independent of BP. This would limit PTT or PAT as accurate BP correlates, more so in resistance vessels than conductance arteries. OBJECTIVE: To quantify if there is a measurable neurogenic effect on PAT measured using photoplethysmography (PPG) (path includes resistance vessels) and radial artery tonometry (path includes only conductance vessels) during physiologically induced BP changes. METHODS: PATs were measured continuously in participants (n=15, 35±15 years, 9 male) using an electrocardiogram and, simultaneously, a Finometer® PRO finger sensor, a finger PPG sensor and radial artery tonometer during seated rest, cold pressor test, cycling and isometric handgrip (IHG) exercise. ΔBP/ΔPAT was calculated for each sensor and each condition. RESULTS: All interventions significantly increased BP. A significant difference was observed in ΔBP/ΔPAT between cycling and both the cold pressor test and IHG exercise (p<0.05). ΔBP/ΔPAT did not differ whether measured via PPG or tonometry. CONCLUSIONS: Under the conditions tested, autonomic function does not have a BP-independent effect on PAT where the path includes resistance vessels (PPG signal), likely due to the speed of the wave and the short path length of resistance vessels. Autonomic function therefore does not limit the ability for use of PPG as a signal for potentially estimating BP without a cuff.

An investigation of the individualized, two-point calibration method for cuffless blood pressure estimation using pulse arrival time: an historical perspective using the Casio BP-100 digital watch.

BACKGROUND: The use of wearable cuffless blood pressure (BP) devices is becoming commercially prevalent with little published validation information. Most devices rely, at least in part, on the relationship between pulse arrival time (PAT) and BP, a theoretical fundamental relationship that was first commercially exploited in 1993 with the release of the Casio BP-100 digital watch. OBJECTIVE: This study explored the PAT method of BP estimation in a commercial device where it first began, the Casio BP-100 (Model No. 900) digital watch, which employs an individualized, two-point calibration method. Device accuracy was determined by comparison to a conventional cuff-based BP device measurements. METHODS: Twenty participants (11 female, 9 male) had BP measured using both devices at rest, during a 5-minute isometric hand-grip exercise and at 1-minute post-exercise. RESULTS: Due to bidirectional scatter of BP estimation by the BP-100 device, there was no significant difference between the reference device and the BP-100. The devices showed poor correlation for both systolic BP (SBP) (R=0.36, p=0.13) and diastolic BP (DBP) (R=0.044, p=0.37). However, on average the watch was able to provide correct directional changes in SBP but not DBP with exercise. CONCLUSIONS: Despite being an industry first, the Casio BP-100 watch employed a method that gives a great chance of accuracy: a two point, individualized calibration method - more detailed than calibration methods in more modern devices. The watch, on average across a cohort, provided some information on BP directional change but was uncorrelated with cuff-based BP measurement. If the utility of beat-by-beat BP estimation is to be utilized, limitations of this method need to be addressed.

Evaluation of the Accuracy of Cuffless Blood Pressure Measurement Devices: Challenges and Proposals.

Several novel cuffless wearable devices and smartphone applications claiming that they can measure blood pressure (BP) are appearing on the market. These technologies are very attractive and promising, with increasing interest among health care professionals for their potential use. Moreover, they are becoming popular among patients with hypertension and healthy people. However, at the present time, there are serious issues about BP measurement accuracy of cuffless devices and the 2021 European Society of Hypertension Guidelines on BP measurement do not recommend them for clinical use. Cuffless devices have special validation issues, which have been recently recognized. It is important to note that the 2018 Universal Standard for the validation of automated BP measurement devices developed by the American Association for the Advancement of Medical Instrumentation, the European Society of Hypertension, and the International Organization for Standardization is inappropriate for the validation of cuffless devices. Unfortunately, there is an increasing number of publications presenting data on the accuracy of novel cuffless BP measurement devices, with inadequate methodology and potentially misleading conclusions. The objective of this review is to facilitate understanding of the capabilities and limitations of emerging cuffless BP measurement devices. First, the potential and the types of these devices are described. Then, the unique challenges in evaluating the BP measurement accuracy of cuffless devices are explained. Studies from the literature and computer simulations are employed to illustrate these challenges. Finally, proposals are given on how to evaluate cuffless devices including presenting and interpreting relevant study results.

Comparison Between Invasive and Noninvasive Methods to Estimate Subendocardial Oxygen Supply and Demand Imbalance.

Background Estimation of the balance between subendocardial oxygen supply and demand could be a useful parameter to assess the risk of myocardial ischemia. Evaluation of the subendocardial viability ratio (SEVR, also known as Buckberg index) by invasive recording of left ventricular and aortic pressure curves represents a valid method to estimate the degree of myocardial perfusion relative to left ventricular workload. However, routine clinical use of this parameter requires its noninvasive estimation and the demonstration of its reliability. Methods and Results Arterial applanation tonometry allows a noninvasive estimation of SEVR as the ratio of the areas directly beneath the central aortic pressure curves obtained during diastole (myocardial oxygen supply) and during systole (myocardial oxygen demand). However, this "traditional" method does not account for the intra-ventricular diastolic pressure and proper allocation to systole and diastole of left ventricular isometric contraction and relaxation, respectively, resulting in an overestimation of the SEVR values. These issues are considered in the novel method for SEVR assessment tested in this study. SEVR values estimated with carotid tonometry by "traditional" and "new" method were compared with those evaluated invasively by cardiac catheterization. The "traditional" method provided significantly higher SEVR values than the reference invasive SEVR: average of differences±SD= 44±11% (limits of agreement: 23% - 65%). The noninvasive "new" method showed a much better agreement with the invasive determination of SEVR: average of differences±SD= 0±8% (limits of agreement: -15% to 16%). Conclusions Carotid applanation tonometry provides valid noninvasive SEVR values only when all the main factors determining myocardial supply and demand flow are considered.