Machine-learning for photoplethysmography analysis: Benchmarking feature, image, and signal-based approaches

Photoplethysmography (PPG) is a widely used non-invasive physiological sensing technique, suitable for various clinical applications. Such clinical applications are increasingly supported by machine learning methods, raising the question of the most appropriate input representation and model choice. Comprehensive comparisons, in particular across different input representations, are scarce. We address this gap in the research landscape by a comprehensive benchmarking study covering three kinds of input representations, interpretable features, image representations and raw waveforms, across prototypical regression and classification use cases: blood pressure and atrial fibrillation prediction. In both cases, the best results are achieved by deep neural networks operating on raw time series as input representations. Within this model class, best results are achieved by modern convolutional neural networks (CNNs). but depending on the task setup, shallow CNNs are often also very competitive. We envision that these results will be insightful for researchers to guide their choice on machine learning tasks for PPG data, even beyond the use cases presented in this work.

Generalizable deep learning for photoplethysmography-based blood pressure estimation -- A Benchmarking Study

Photoplethysmography (PPG)-based blood pressure (BP) estimation represents a promising alternative to cuff-based BP measurements. Recently, an increasing number of deep learning models have been proposed to infer BP from the raw PPG waveform. However, these models have been predominantly evaluated on in-distribution test sets, which immediately raises the question of the generalizability of these models to external datasets. To investigate this question, we trained five deep learning models on the recently released PulseDB dataset, provided in-distribution benchmarking results on this dataset, and then assessed out-of-distribution performance on several external datasets. The best model (XResNet1d101) achieved in-distribution MAEs of 9.4 and 6.0 mmHg for systolic and diastolic BP respectively on PulseDB (with subject-specific calibration), and 14.0 and 8.5 mmHg respectively without calibration. Equivalent MAEs on external test datasets without calibration ranged from 15.0 to 25.1 mmHg (SBP) and 7.0 to 10.4 mmHg (DBP). Our results indicate that the performance is strongly influenced by the differences in BP distributions between datasets. We investigated a simple way of improving performance through sample-based domain adaptation and put forward recommendations for training models with good generalization properties. With this work, we hope to educate more researchers for the importance and challenges of out-of-distribution generalization.

Artificial Intelligence-derived Vascular Age from Photoplethysmography: A Novel Digital Biomarker for Cardiovascular Health

With the increasing availability of wearable devices, photoplethysmography (PPG) has emerged as a promising non-invasive tool for monitoring human hemodynamics. We propose a deep learning framework to estimate vascular age (AI-vascular age) from PPG signals, incorporating a distribution-aware loss to address biases caused by imbalanced data. The model was developed using data from the UK Biobank (UKB), with 98,672 participants in the development cohort and 113,559 participants (144,683 data pairs) for clinical evaluation. After adjusting for key confounders, individuals with a vascular age gap (AI-vascular age minus calendar age) exceeding 9 years had a significantly higher risk of major adverse cardiovascular and cerebrovascular events (MACCE) (HR = 2.37, p < 0.005) and secondary outcomes, including diabetes (HR = 2.69, p < 0.005), hypertension (HR = 2.88, p < 0.005), coronary heart disease (HR = 2.20, p < 0.005), heart failure (HR = 2.15, p < 0.005), myocardial infarction (HR = 2.51, p < 0.005), stroke (HR = 2.55, p < 0.005), and all-cause mortality (HR = 2.51, p < 0.005). Conversely, participants with a vascular age gap below -9 years exhibited a significantly lower incidence of these outcomes. We further evaluated the longitudinal applicability of AI-vascular age using serial PPG data from the UKB, demonstrating its value in risk stratification by leveraging AI-vascular age at two distinct time points to predict future MACCE incidence. External validation was performed on a MIMIC-III-derived cohort (n = 2,343), where each one-year increase in vascular age gap was significantly associated with elevated in-hospital mortality risk (OR = 1.02, p < 0.005). In conclusion, our study establishes AI-vascular age as a novel, non-invasive digital biomarker for cardiovascular health assessment.

Joint Attention Mechanism Learning to Facilitate Opto-physiological Monitoring during Physical Activity

Opto-physiological monitoring is a non-contact technique for measuring cardiac signals, i.e., photoplethysmography (PPG). Quality PPG signals directly lead to reliable physiological readings. However, PPG signal acquisition procedures are often accompanied by spurious motion artefacts (MAs), especially during low-to-high-intensity physical activity. This study proposes a practical adversarial learning approach for opto-physiological monitoring by using a generative adversarial network with an attention mechanism (AM-GAN) to model motion noise and to allow MA removal. The AM-GAN learns an MA-resistant mapping from raw and noisy signals to clear PPG signals in an adversarial manner, guided by an attention mechanism to directly translate the motion reference of triaxial acceleration to the MAs appearing in the raw signal. The AM-GAN was experimented with three various protocols engaged with 39 subjects in various physical activities. The average absolute error for heart rate (HR) derived from the MA-free PPG signal via the AM-GAN, is 1.81 beats/min for the IEEE-SPC dataset and 3.86 beats/min for the PPGDalia dataset. The same procedure applied to an in-house LU dataset resulted in average absolute errors for HR and respiratory rate (RR) of less than 1.37 beats/min and 2.49 breaths/min, respectively. The study demonstrates the robustness and resilience of AM-GAN, particularly during low-to-high-intensity physical activities.

Continuous Cardiac Arrest Prediction in ICU using PPG Foundation Model

Non-invasive patient monitoring for tracking and predicting adverse acute health events is an emerging area of research. We pursue in-hospital cardiac arrest (IHCA) prediction using only single-channel finger photoplethysmography (PPG) signals. Our proposed two-stage model Feature Extractor-Aggregator Network (FEAN) leverages powerful representations from pre-trained PPG foundation models (PPG-GPT of size up to 1 Billion) stacked with sequential classification models. We propose two FEAN variants ("1H", "FH") which use the latest one-hour and (max) 24-hour history to make decisions respectively. Our study is the first to present IHCA prediction results in ICU patients using only unimodal (continuous PPG signal) waveform deep representations. With our best model, we obtain an average of 0.79 AUROC over 24~h prediction window before CA event onset with our model peaking performance at 0.82 one hour before CA. We also provide a comprehensive analysis of our model through architectural tuning and PaCMAP visualization of patient health trajectory in latent space.

Pulse-PPG: An Open-Source Field-Trained PPG Foundation Model for Wearable Applications Across Lab and Field Settings

Photoplethysmography (PPG)-based foundation models are gaining traction due to the widespread use of PPG in biosignal monitoring and their potential to generalize across diverse health applications. In this paper, we introduce Pulse-PPG, the first open-source PPG foundation model trained exclusively on raw PPG data collected over a 100-day field study with 120 participants. Existing PPG foundation models are either open-source but trained on clinical data or closed-source, limiting their applicability in real-world settings. We evaluate Pulse-PPG across multiple datasets and downstream tasks, comparing its performance against a state-of-the-art foundation model trained on clinical data. Our results demonstrate that Pulse-PPG, trained on uncurated field data, exhibits superior generalization across clinical and mobile health applications in both lab and field settings. This suggests that exposure to real-world variability enables the model to learn fine-grained representations, making it more adaptable across tasks. Furthermore, pre-training on field data surprisingly outperforms its pre-training on clinical data in many tasks, reinforcing the importance of training on real-world, diverse datasets. To encourage further advancements in robust foundation models leveraging field data, we plan to release Pulse-PPG, providing researchers with a powerful resource for developing more generalizable PPG-based models.

CodePhys: Robust Video-based Remote Physiological Measurement through Latent Codebook Querying

Remote photoplethysmography (rPPG) aims to measure non-contact physiological signals from facial videos, which has shown great potential in many applications. Most existing methods directly extract video-based rPPG features by designing neural networks for heart rate estimation. Although they can achieve acceptable results, the recovery of rPPG signal faces intractable challenges when interference from real-world scenarios takes place on facial video. Specifically, facial videos are inevitably affected by non-physiological factors (e.g., camera device noise, defocus, and motion blur), leading to the distortion of extracted rPPG signals. Recent rPPG extraction methods are easily affected by interference and degradation, resulting in noisy rPPG signals. In this paper, we propose a novel method named CodePhys, which innovatively treats rPPG measurement as a code query task in a noise-free proxy space (i.e., codebook) constructed by ground-truth PPG signals. We consider noisy rPPG features as queries and generate high-fidelity rPPG features by matching them with noise-free PPG features from the codebook. Our approach also incorporates a spatial-aware encoder network with a spatial attention mechanism to highlight physiologically active areas and uses a distillation loss to reduce the influence of non-periodic visual interference. Experimental results on four benchmark datasets demonstrate that CodePhys outperforms state-of-the-art methods in both intra-dataset and cross-dataset settings.

Tri-Spectral PPG: Robust Reflective Photoplethysmography by Fusing Multiple Wavelengths for Cardiac Monitoring

Multi-channel photoplethysmography (PPG) sensors have found widespread adoption in wearable devices for monitoring cardiac health. Channels thereby serve different functions -- whereas green is commonly used for metrics such as heart rate and heart rate variability, red and infrared are commonly used for pulse oximetry. In this paper, we introduce a novel method that simultaneously fuses multi-channel PPG signals into a single recovered PPG signal that can be input to further processing. Via signal fusion, our learning-based method compensates for the artifacts that affect wavelengths to different extents, such as motion and ambient light changes. We evaluate our method on a novel dataset of multi-channel PPG recordings and electrocardiogram recordings for reference from 10 participants over the course of 13 hours during real-world activities outside the laboratory. Using the fusion PPG signal our method recovered, participants' heart rates can be calculated with a mean error of 4.5\,bpm (23\% lower than from green PPG signals at 5.9\,bpm).

Robust Heart Rate Detection via Multi-Site Photoplethysmography

Smartwatches have become popular for monitoring physiological parameters outside clinical settings. Using reflective photoplethysmography (PPG) sensors, such watches can non-invasively estimate heart rate (HR) in everyday environments and throughout a patient's day. However, achieving consistently high accuracy remains challenging, particularly during moments of increased motion or due to varying device placement. In this paper, we introduce a novel sensor fusion method for estimating HR that flexibly combines samples from multiple PPG sensors placed across the patient's body, including wrist, ankle, head, and sternum (chest). Our method first estimates signal quality across all inputs to dynamically integrate them into a joint and robust PPG signal for HR estimation. We evaluate our method on a novel dataset of PPG and ECG recordings from 14 participants who engaged in real-world activities outside the laboratory over the course of a whole day. Our method achieves a mean HR error of 2.4\,bpm, which is 46\% lower than the mean error of the best-performing single device (4.4\,bpm, head).

Detecting Cognitive Impairment and Psychological Well-being among Older Adults Using Facial, Acoustic, Linguistic, and Cardiovascular Patterns Derived from Remote Conversations

The aging society urgently requires scalable methods to monitor cognitive decline and identify social and psychological factors indicative of dementia risk in older adults. Our machine learning (ML) models captured facial, acoustic, linguistic, and cardiovascular features from 39 individuals with normal cognition or Mild Cognitive Impairment derived from remote video conversations and classified cognitive status, social isolation, neuroticism, and psychological well-being. Our model could distinguish Clinical Dementia Rating Scale (CDR) of 0.5 (vs. 0) with 0.78 area under the receiver operating characteristic curve (AUC), social isolation with 0.75 AUC, neuroticism with 0.71 AUC, and negative affect scales with 0.79 AUC. Recent advances in machine learning offer new opportunities to remotely detect cognitive impairment and assess associated factors, such as neuroticism and psychological well-being. Our experiment showed that speech and language patterns were more useful for quantifying cognitive impairment, whereas facial expression and cardiovascular patterns using photoplethysmography (PPG) were more useful for quantifying personality and psychological well-being.