The quest for blood pressure markers in photoplethysmography and its applications in digital health.

Introduction: Photoplethysmography (PPG) sensors, capturing optical signals from arterial pulses, are debated for their potential in blood pressure (BP) measurement. This study employed the largest dataset to date of paired PPG and cuff BP readings to explore PPG signals for BP estimation. Methods: 32,152 European residents (age 55.9% ± 11.8, 24% female, BMI 27.7 ± 4.6) voluntarily acquired and used a cuffless BP monitor (Aktiia SA, Switzerland) between March/2,021-March/2023. Systolic and diastolic BP (SBP, DBP) from an upper arm oscillometric cuff were collected simultaneously with wrist PPG (668,080 paired measurements). Six different machine learning models were developed to predict BP using cuff BP readings as reference (75%|15%|15% training|validation|testing): four baseline models [heart rate (HR), Age, Demography (DEM: Age + Gender + BMI), DEM + HR], and two models relying on the analysis of the PPG waveforms (PPG, PPG + DEM). Performance of each model was evaluated on the 4,823 subjects from the testing set using as metrics the Pearson's correlation (r) when comparing the estimated and the reference BP values, and the area under the receiver operating characteristic (AUROC) curves, and true positive and true negative rates (TPR, TNR) for the detection of high BP (reference SBP ≥ 140 or DBP ≥ 90 mmHg, applying a ± 8 mmHg exclusion zone to account for cuff measurement uncertainty). Results: Baseline models showed low correlation with cuff data and poor high BP detection ( Discussion: This study demonstrated that PPG signals contain reliable markers of BP, and that BP values can be estimated using only markers found within PPG's optical pulsatility signals, outperforming models based solely on demographic data. These findings hold the potential to radically transform hypertension screening and global healthcare delivery, paving the way for innovative approaches in patient diagnosis, monitoring and treatment methodologies.