Examination of normalized pulse volume-blood volume relationship: toward a more valid estimation of the finger sympathetic tone

Frequency-Domain Features and Low-Frequency Synchronization of Photoplethysmographic Waveform Variability and Heart Rate Variability with Increasing Severity of Cardiovascular Diseases

Objective-Heart rate variability (HRV) and photoplethysmographic waveform variability (PPGV) are available approaches for assessing the state of cardiovascular autonomic regulation. The goal of our study was to compare the frequency-domain features and low-frequency (LF) synchronization of the PPGV and HRV with increasing severity of cardiovascular diseases. Methods-Our study included 998 electrocardiogram (ECG) and finger photoplethysmogram (PPG) recordings from subjects, classified into five categories: 53 recordings from healthy subjects, aged 28.1 ± 6.2 years, 536 recordings from patients with hypertension (HTN), 49.0 ± 8.8 years old, 185 recordings from individuals with stable coronary artery disease (CAD) (63.9 ± 9.3 years old), 104 recordings from patients with myocardial infarction (MI) that occurred three months prior to the recordings (PMI) (65.1 ± 11.0 years old), and 120 recordings from study subjects with acute myocardial infarction (AMI) (64.7 ± 11.5 years old). Spectral analyses of the HRV and PPGV were carried out, along with an assessment of the synchronization strength between LF oscillations of the HRV and of PPGV (synchronization index). Results-Changes in all frequency-domain indices and the synchronization index were observed along the following gradient: healthy subjects → patients with HTN → patients with CAD → patients with PMI → patients with AMI. Similar frequency-domain indices of the PPGV and HRV show little relationship with each other. Conclusions-The frequency-domain indices of the PPGV are highly sensitive to the development of any cardiovascular disease and, therefore, are superior to the HRV indices in this regard. The S index is an independent parameter from the frequency-domain indices.

Wolf Creek XVII Part 6: Physiology-Guided CPR

Introduction

Physiology-guided cardiopulmonary resuscitation (CPR) offers the potential to optimize resuscitation and enable early prognosis.

Methods

Physiology-Guided CPR was one of six focus topic for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. International thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry were invited. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category, which was then debated, revised and ranked by all attendees to identify the top 5 for each category.

Results

Top knowledge gaps include identifying optimal strategies for the evaluation of physiology-guided CPR and the optimal values for existing patients using patient outcomes. The main barriers to translation are the limited usability outside of critical care environments and the training and equipment required for monitoring. The top research priorities are the development of clinically feasible and reliable methods to continuously and non-invasively monitor physiology during CPR and prospective human studies proving targeting parameters during CPR improves outcomes.

Conclusion

Physiology-guided CPR has the potential to provide individualized resuscitation and move away from a one-size-fits-all approach. Current understanding is limited, and clinical trials are lacking. Future developments need to consider the clinical application and applicability of measurement to all healthcare settings. Therefore, clinical trials using physiology-guided CPR for individualisation of resuscitation efforts are needed.

Validity of Smartphone Heart Rate Variability Pre- and Post-Resistance Exercise

The aim was to examine the validity of heart rate variability (HRV) measurements from photoplethysmography (PPG) via a smartphone application pre- and post-resistance exercise (RE) and to examine the intraday and interday reliability of the smartphone PPG method. Thirty-one adults underwent two simultaneous ultrashort-term electrocardiograph (ECG) and PPG measurements followed by 1-repetition maximum testing for back squats, bench presses, and bent-over rows. The participants then performed RE, where simultaneous ultrashort-term ECG and PPG measurements were taken: two pre- and one post-exercise. The natural logarithm of the root mean square of successive normal-to-normal (R-R) differences (LnRMSSD) values were compared with paired-sample t-tests, Pearson product correlations, Cohen’s d effect sizes (ESs), and Bland–Altman analysis. Intra-class correlations (ICC) were determined between PPG LnRMSSDs. Significant, small–moderate differences were found for all measurements between ECG and PPG: Base_Pre1 (ES = 0.42), Base_Pre2 (0.30), RE_Pre1 (0.26), RE_Pre2 (0.36), and RE_Post (1.14). The correlations ranged from moderate to very large: Base_Pre1 (r = 0.59), Base_Pre2 (r = 0.63), RE_Pre1 (r = 0.63), RE_Pre2 (r = 0.76), and RE_Post (r = 0.41)—all p < 0.05. The agreement for all the measurements was “moderate” (0.10–0.16). The PPG LnRMSSD exhibited “nearly-perfect” intraday reliability (ICC = 0.91) and “very large” interday reliability (0.88). The smartphone PPG was comparable to the ECG for measuring HRV at rest, but with larger error after resistance exercise.

Selective attention, not cognitive load, elicited fewer eyeblinks in a concealed information test

The concealed information test (CIT), a memory detection test, compares physiological responses to crime-related and crime-unrelated items. This study elucidated processes involving spontaneous eyeblinks during the CIT by manipulating participants' intention to conceal. Thirty-four participants committed mock theft. In the CIT, wherein eyeblinks are measured simultaneously with autonomic responses, the secret group concealed the crime-related item, whereas the no-secret group did not. As a result, heart rate (HR) was modulated by the intention of concealment in autonomic measures, whereas the effect of concealment on the decrease of eyeblinks was not found to be significant. In addition, the latency of the first eyeblink was longer for the crime-related item in both groups. These results imply that CIT eyeblinks mainly involve the process of selective attention for the item, and the latency of the first eyeblink reflects a delay in attentional disengagement from the item. This study also suggested that there is still room for improvement in simultaneously measuring eyeblinks and autonomic responses in the CIT.

The Act of Answering Questions Elicited Differentiated Responses in a Concealed Information Test

The concealed information test (CIT), a psychophysiological detection of deception test, compares physiological responses between crime-related and crime-unrelated items. In previous studies, whether the act of answering questions affected physiological responses was unclear. This study examined effects of both question-related and answer-related processes on physiological responses. Twenty participants received a modified CIT, in which the interval between presentation of questions and answering them was 27 s. Differentiated respiratory movements and cardiovascular responses between items were observed for both questions (items) and answers, while differentiated skin conductance response was observed only for questions. These results suggest that physiological responses to questions reflected orientation to a crime-related item, while physiological responses during answering reflected inhibition of psychological arousal caused by orienting. Regarding the CIT's accuracy, participants' perception of the questions themselves more strongly influenced physiological responses than answering them.

Mitigation of stress: new treatment alternatives

Complaints of stress are common in modern life. Psychological stress is a major cause of lifestyle-related issues, contributing to poor quality of life. Chronic stress impedes brain function, causing impairment of many executive functions, including working memory, decision making and attentional control. The current study sought to describe newly developed stress mitigation techniques, and their influence on autonomic and endocrine functions. The literature search revealed that the most frequently studied technique for stress mitigation was biofeedback (BFB). However, evidence suggests that neurofeedback (NFB) and noninvasive brain stimulation (NIBS) could potentially provide appropriate approaches. We found that recent studies of BFB methods have typically used measures of heart rate variability, respiration and skin conductance. In contrast, studies of NFB methods have typically utilized neurocomputation techniques employing electroencephalography, functional magnetic resonance imaging and near infrared spectroscopy. NIBS studies have typically utilized transcranial direct current stimulation methods. Mitigation of stress is a challenging but important research target for improving quality of life.

Pulse Transit Time Based Continuous Cuffless Blood Pressure Estimation: A New Extension and A Comprehensive Evaluation

Cuffless technique enables continuous blood pressure (BP) measurement in an unobtrusive manner, and thus has the potential to revolutionize the conventional cuff-based approaches. This study extends the pulse transit time (PTT) based cuffless BP measurement method by introducing a new indicator – the photoplethysmogram (PPG) intensity ratio (PIR). The performance of the models with PTT and PIR was comprehensively evaluated in comparison with six models that are based on sole PTT. The validation conducted on 33 subjects with and without hypertension, at rest and under various maneuvers with induced BP changes, and over an extended calibration interval, respectively. The results showed that, comparing to the PTT models, the proposed methods achieved better accuracy on each subject group at rest state and over 24 hours calibration interval. Although the BP estimation errors under dynamic maneuvers and over extended calibration interval were significantly increased for all methods, the proposed methods still outperformed the compared methods in the latter situation. These findings suggest that additional BP-related indicator other than PTT has added value for improving the accuracy of cuffless BP measurement. This study also offers insights into future research in cuffless BP measurement for tracking dynamic BP changes and over extended periods of time.

iPhone 4s photoplethysmography: which light color yields the most accurate heart rate and normalized pulse volume using the iPhysioMeter Application in the presence of motion artifact?

Recent progress in information and communication technologies has made it possible to measure heart rate (HR) and normalized pulse volume (NPV), which are important physiological indices, using only a smartphone. This has been achieved with reflection mode photoplethysmography (PPG), by using a smartphone's embedded flash as a light source and the camera as a light sensor. Despite its widespread use, the method of PPG is susceptible to motion artifacts as physical displacements influence photon propagation phenomena and, thereby, the effective optical path length. Further, it is known that the wavelength of light used for PPG influences the photon penetration depth and we therefore hypothesized that influences of motion artifact could be wavelength-dependant. To test this hypothesis, we made measurements in 12 healthy volunteers of HR and NPV derived from reflection mode plethysmograms recorded simultaneously at three different spectral regions (red, green and blue) at the same physical location with a smartphone. We then assessed the accuracy of the HR and NPV measurements under the influence of motion artifacts. The analyses revealed that the accuracy of HR was acceptably high with all three wavelengths (all rs > 0.996, fixed biases: -0.12 to 0.10 beats per minute, proportional biases: r =  -0.29 to 0.03), but that of NPV was the best with green light (r = 0.791, fixed biases: -0.01 arbitrary units, proportional bias: r = 0.11). Moreover, the signal-to-noise ratio obtained with green and blue light PPG was higher than that of red light PPG. These findings suggest that green is the most suitable color for measuring HR and NPV from the reflection mode photoplethysmogram under motion artifact conditions. We conclude that the use of green light PPG could be of particular benefit in ambulatory monitoring where motion artifacts are a significant issue.

Validation of normalized pulse volume in the outer ear as a simple measure of sympathetic activity using warm and cold pressor tests: towards applications in ambulatory monitoring

Normalized pulse volume (NPV) derived from the ear has the potential to be a practical index for monitoring daily life stress. However, ear NPV has not yet been validated. Therefore, we compared NPV derived from an index finger using transmission photoplethysmography as a reference, with NPV derived from a middle finger and four sites of the ear using reflection photoplethysmography during baseline and while performing cold and warm water immersion in ten young and six middle-aged subjects. The results showed that logarithmically-transformed NPV (lnNPV) during cold water immersion as compared with baseline values was significantly lower, only at the index finger, the middle finger and the bottom of the ear-canal. Furthermore, lnNPV reactivities (ΔlnNPV; the difference between baseline and test values) from an index finger were significantly related to ΔlnNPV from the middle finger and the bottom of the ear-canal (young: r = 0.90 and 0.62, middle-aged: r = 0.80 and 0.58, respectively). In conclusion, these findings show that reflection and transmission photoplethysmography are comparable methods to derive NPV in accordance with our theoretical prediction. NPV derived from the bottom of the ear-canal is a valid approach, which could be useful for evaluating daily life stress.

Relations between ac-dc components and optical path length in photoplethysmography

Photoplethysmography is used in various areas such as vital sign measurement, vascular characteristics analysis, and autonomic nervous system assessment. Photoplethysmographic signals are composed of ac and dc, but it is difficult to find research about the interaction of photoplethysmographic components. This study suggested a model equation combining two Lambert-Beer equations at the onset and peak points of photoplethysmography to evaluate ac characteristics, and verified the model equation through simulation and experiment. In the suggested equation, ac was dependent on dc and optical path length. In the simulation, dc was inversely proportionate to ac sensitivity (slope), and ac and optical path length were proportionate. When dc increased from 10% to 90%, stabilized ac decreased from 1 to 0.89 ± 0.21, and when optical path length increased from 10% to 90%, stabilized ac increased from 1 to 1.53 ± 0.40.

Differential response of peripheral arterial compliance-related indices to a vasoconstrictive stimulus

Peripheral arterial elastic properties are greatly affected by cardiovascular as well as other pathologies, and their assessment can provide useful diagnostic indicators. The photoplethysmographic technique can provide finger blood volume and pressure waveforms non-invasively, which can then be processed statically or beat-to-beat to characterize parameters of the vessel wall mechanics. We employ an occlusion-deflation protocol in 48 healthy volunteers to study peripheral artery compliance-related indices over positive and negative transmural pressure values as well as under the influence of a valid vasoconstrictor (cigarette smoking). We calculate beat-to-beat indices (compliance index CI, distensibility index DI, three viscoelastic model parameters (compliance C, viscosity R and inertia L), pressure-volume loop areas A and damping factor DF as well as symmetrical (C(max)) and asymmetrical (C(A)(max)) static compliance estimates, and their distributions over transmural pressure. All distributions are bell-shaped and centred on negative transmural pressure values. Distribution heights were significantly lower in the smoking group (w.r.t. the non-smoking group) for C, CI, DI and significantly higher in R and DF. The estimated volume signal time lag was also significantly lower in the smoking group. Left and right distribution widths were significantly different in all parameters/groups but DI (both groups), C(A)(max), A (smoking group) and L (non-smoking group), and positions of maxima/minima were significantly altered in C(A)(max), R and DF. C, DF and CI are seen to be most sensitive under this protocol, while C(max) and C(A)(max) are seen to be insensitive. These quantities provide complementary, time- and transmural pressure-dependent information about arterial wall mechanics, and the choice of index should depend on the physiological conditions at hand as well as relevant time resolution and transmural pressure range.

Photoplethysmography and its application in clinical physiological measurement

Photoplethysmography (PPG) is a simple and low-cost optical technique that can be used to detect blood volume changes in the microvascular bed of tissue. It is often used non-invasively to make measurements at the skin surface. The PPG waveform comprises a pulsatile ('AC') physiological waveform attributed to cardiac synchronous changes in the blood volume with each heart beat, and is superimposed on a slowly varying ('DC') baseline with various lower frequency components attributed to respiration, sympathetic nervous system activity and thermoregulation. Although the origins of the components of the PPG signal are not fully understood, it is generally accepted that they can provide valuable information about the cardiovascular system. There has been a resurgence of interest in the technique in recent years, driven by the demand for low cost, simple and portable technology for the primary care and community based clinical settings, the wide availability of low cost and small semiconductor components, and the advancement of computer-based pulse wave analysis techniques. The PPG technology has been used in a wide range of commercially available medical devices for measuring oxygen saturation, blood pressure and cardiac output, assessing autonomic function and also detecting peripheral vascular disease. The introductory sections of the topical review describe the basic principle of operation and interaction of light with tissue, early and recent history of PPG, instrumentation, measurement protocol, and pulse wave analysis. The review then focuses on the applications of PPG in clinical physiological measurements, including clinical physiological monitoring, vascular assessment and autonomic function.

Extraction of photoplethysmographic waveform variability by lowpass filtering

Cardiovascular variability is known to provide useful physiological information about autonomic function and peripheral vascular tone. Previous studies have used systolic values (peaks) or diastolic values (troughs) in the photoplethysmographic signal (PPG) to represent the variability in the finger pulse waveform. However, the feature detection process is error prone and often requires manual correction which is time consuming. The current study has proposed the lowpass filtering method as an alternative means to extract the variability signal. The similarities between the lowpass filtered spectrum and the spectra produced by other representation methods were assessed quantitatively via the computation of normalized cross-correlations. Results showed that the lowpass filtered signal produced a variability spectrum which was nearly identical to that of the pulse waveform mean value (correlation = 0.996), and was highly correlated with the trough and the peak variability spectra (correlation > 0.9). Compared with feature extraction methods, the lowpass filtering method is much simpler and computationally efficient to implement. In addition, the lowpass filtering method can be applied in conjunction with signal decomposition techniques such as principal component analysis (PCA) to better quantify sympathetic change.