sensors

Article
Wearable Piezoelectric-Based System for Continuous
Beat-to-Beat Blood Pressure Measurement
Ting-Wei Wang 1 and Shien-Fong Lin 1,2,3, *
1 Department of Electrical and Computer Engineering, College of Electrical and Computer Engineering,
National Chiao Tung University, Hsinchu 30010, Taiwan; [email protected]
2 Institute of Biomedical Engineering, College of Electrical and Computer Engineering, National Chiao Tung
University, Hsinchu 30010, Taiwan
3 Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
* Correspondence: [email protected]




Received: 16 January 2020; Accepted: 4 February 2020; Published: 5 February 2020


Abstract: Non-invasive continuous blood pressure measurement is an emerging issue that potentially
can be applied to cardiovascular disease monitoring and prediction. Recently, many groups
have proposed the pulse transition time (PTT) method to estimate blood pressure for long-term
monitoring. However, the PTT-based methods for blood pressure estimation are limited by non-specific
estimation models and require multiple calibrations. This study aims to develop a low-cost wearable
piezoelectric-based system for continuous beat-to-beat blood pressure measurement. The pressure
change in the radial artery was extracted by systolic and diastolic feature points in pressure pulse
wave (PPW) and the pressure sensitivity of the sensor. The proposed system showed a reliable
accuracy of systolic blood pressure (SBP) (mean absolute error (MAE) ± standard deviation (SD)
1.52 ± 0.30 mmHg) and diastolic blood pressure (DBP, MAE ± SD 1.83 ± 0.50), and its performance
agreed with standard criteria of MAE within 5 mmHg and SD within ±8 mmHg. In conclusion, this
study successfully developed a low-cost, high-accuracy piezoelectric-based system for continuous
beat-to-beat SBP and DBP measurement without multiple calibrations and complex regression analysis.
The system is potentially suitable for continuous, long-term blood pressure-monitoring applications.

Keywords: continuous blood pressure; piezoelectric sensor; wearable device

1. Introduction
Blood pressure measurement is an essential technique used in cardiovascular disease monitoring.
The auscultatory and oscillometric methods, which use the cuff sensor to detect systolic blood pressure
(SBP) and diastolic blood pressure (DBP), are the golden benchmark and commonly used in clinical
diagnosis. However, the cuff-based technique only provides one-shot data without continuous blood
pressure information and causes inconvenience due to repeated cuff inflations. Therefore, a significant
limitation of the cuff-based approach is the lack of continuous monitoring of adverse events for
hypertensive patients. On the other hand, the arterial cannula is a precise method to directly measure
continuous blood pressure, but the arterial cannula method uses a catheter inserted into the blood
vessel that could induce potential risk by such an invasive method [1]. Consequently, the non-invasive
continuous blood pressure monitoring remains a significant clinical unmet need.
Many groups have proposed methods based on pulse transition time (PTT) for continuous blood
pressure monitoring [2–4]. PTT represents the estimated propagation time of a pulse wave measured
between two sites of the artery [5,6]. PTT is frequently extracted from two-channel physiological
signals, including electrocardiography (ECG) and photoplethysmography (PPG). PTT is determined
by the time delay between the R-peak of the ECG signal and the time point of the maximum slope

Sensors 2020, 20, 851; doi:10.3390/s20030851 www.mdpi.com/journal/sensors

Sensors 2020, 20, 851 2 of 12

of the PPG waveform [7,8]. The PTT can also be estimated from two-channel PPG signals recorded
from two different locations to calculate the time delay between both waveforms [9,10]. Many
studies presented several PTT-based mathematical models for blood pressure estimation by different
models [11], including logarithmic model [12], linear model [13], inverse square model [14], and inverse
model [15]. The regression coefficients of these models were obtained by multiple calibrations between
the oscillometric method (the gold standard) and PPT-based technique to determine the accuracy of
the model. At present, the application of PTT-based methods is limited by technical considerations,
including the appropriate two-channel physiological measurement, non-specific estimation models
and a complex procedure of multiple calibrations.
In order to deploy a wearable device with a one-channel physiological measurement, some studies
provided a pressure sensor to achieve continuous blood pressure monitoring. The pulsation changes in
the artery can be detected by a pressure sensor such as the capacitive pressure sensor and piezoelectric
sensor, which were usually used in blood pressure applications depending on the pressure sensitivity
of the device. The capacitive pressure sensor uses the mechanism of distance change between two
parallel plates to estimate blood pressure change in the artery. However, capacitive pressure sensors are
typically characterized by low-pressure sensitivities due to the small stress from arterial compression.
Kim et al. [16] presented a modified structure of the dielectric layer by PDMS spacer and wrinkle
gold foil to improve the sensitivity of the capacitive pressure sensor for blood pressure measurement
application. Compared to the capacitive pressure sensor, a piezoelectric sensor directly converts
the pressure signals into electrical signals by pressure sensitivity (mV/mmHg) of the piezoelectric
sensor. The radial artery of the wrist is the common site to measure continuous pressure pulse wave
(PPW) signals by a piezoelectric sensor. For example, Liu et al. [17] demonstrated a PPW-based blood
pressure estimation models by piezoelectric sensor implementation and a linear regression method to
demonstrate the low mean absolute error (MAE) of blood pressure measurement, compared to the
cuff method. Recently, Kaisti et al. [18] developed a wearable microelectromechanical system (MEMS)
that produced a high correlation of mean arterial pressure (MAP) between the non-invasive pulse
measurement and the invasive pulse waveform.
Most of these previous studies sought to increase accuracy through complicated mathematical
models and calculations. Alternatively, an intuitive computation and reliable accuracy are preferable
for practical applications in continuous beat-to-beat blood-pressure measurement. The main aim of this
paper is to develop a wearable piezoelectric-based system to provide an intuitive strategy that uses the
summation of initial blood pressure and pressure change for beat-to-beat SBP and DBP measurement
without the cumbersome multiple calibrations.

2. Measurement Strategy
The measurement strategy uses the sum of the initial blood pressure measured by a cuff-based
sensor (HEM-1000, OMRON) with oscillmotric method and pressure changes obtained by a calibrated
piezoelectric sensor to achieve beat-to-beat SBP and DBP monitoring, according to Equation (1).

P(t) = Pinitial + ∆P (1)

The changes in the pressure of the artery can be calculated by the pressure sensitivity of the
piezoelectric sensor. The step-by-step procedure of the measurement strategy is the following:

Step 1: The initial blood pressure is measured by the cuff method.

Step 2: The pressure signals from the radial artery are converted to an electrical signal through
the piezoelectric sensor. Continuous PPW signals are filtered and amplified by the front-end
analog circuit
Step 3: The voltage change of SBP and DBP feature points is identified within the adjacent PPW signals
(Figure 1a).
Sensors 2020, 20, 851 3 of 12

Step 4: The voltage change (∆mV) of SBP and DBP feature points are converted to pressure change
(∆mmHg) of SBP and DBP by the pressure sensitivity of the piezoelectric sensor (Figure 1b).
Step 5: Sum of initial blood pressure by cuff method and pressure changes by the piezoelectric sensor
to achieve beat-to-beat SBP and DBP monitoring, according to Equations (2) and (3) (Figure 2)

SBP(t) = SBPcu f f , initial + ∆mmHg1 + ∆mmHg2 + . . . (2)

DBP(t) = DBPcu f f , initial + ∆mmHga + ∆mmHgb + . . . (3)

Figure 1. (a) Calculate the ∆mV at the systolic blood pressure (SBP) and diastolic blood pressure (DBP)
feature points within the adjacent wave. (b) Convert the voltage change (∆mV) into pressure change
(∆mmHg) by the pressure sensitivity of the piezoelectric sensor (mV/mmHg).

Figure 2. Continuous beat-to-beat SBP and DBP monitoring.

3. System Design
The system can be described in three main parts, including piezoelectric sensor, front-end analog
circuit, and software processing unit (Figure 3). The piezoelectric sensor provides a sensing function
of pulsation changes of the radial artery that converts pressure signals into electrical signals by the
pressure sensitivity of the piezoelectric sensor. The front-end analog circuit is responsible for PPW
amplification and filtering. The round piezoelectric sensor and the analog frontend circuit were
constructed with geometric dimensions of 2.4 cm in diameter and 5 cm × 7 cm, respectively. The
post-processing unit is responsible for detecting SBP and DBP feature points and calculating pressure
changes between the adjacent waves.
Sensors 2020, 20, 851 4 of 12

Figure 3. Schematic of the overall system.

3.1. Piezoelectric Sensor

The pulsation signal from the radial artery is a weak signal, which is highly susceptible to
interference from electric and magnetic fields during the detection procedure. Therefore, the sensitivity,
resolution, and anti-interference ability of the sensor must be considered when detecting the PPW
signals. A piezoelectric module HK-2000B (Hefei Huake Electronic Technology Research Institute, Hefei,
China) was used in this study. The HK-2000B is a medical pulse sensor that uses piezoelectric-sensitive
materials of polyvinylidene fluoride (PVDF) film, which directly converts the arterial pressure signals
into electrical signals. The main characteristics of HK-2000B are high sensitivity (2 mV/mmHg) and
wide pressure detection range (−50–3000 mmHg). The piezoelectric sensor was mounted on the
subject’s wrist above the radial artery by a wrist strap, which can maintain stable mechanical coupling
of the sensor with the skin (Figure 4).

Figure 4. Piezoelectric sensor measurement location.

3.2. Front-End Analog Circuit

In order to extract clear PPW signals, a front-end analog circuit is required to process signals
obtained from the piezoelectric sensor. The front-end analog circuit can be divided into two parts,
including the alternating current (AC)-coupling circuit and amplifier circuit. The AC-coupling circuit
is responsible for direct current (DC) removal in bio-potential measurements [19] that provides a
differential high-pass filter without the grounded resistors to eliminate baseline wandering in front
of the amplifier circuit [20]. The AC-coupling circuit was designed with a cutoff frequency of 0.03
Hz, according to Equation (4). In addition, the high impedance voltage followers were behind the
AC-coupling circuit to avoid the signals to attenuate.

1
fc = (4)
2πR y Cx
Sensors 2020, 20, 851 5 of 12

AD620 instrumentation amplifiers (Analog Devices Inc., Norwood, MA, USA) were used for
signal amplification with optimal power supply of ±15 V that was provided by the data acquisition
(DAQ) device with ±15 V DC power source. The AD620 provides a tunable gain of 1 to 10,000 by an
external resistor, according to Equation (5). This study chose the gain of 989 using RG of 50 Ω with
a high common-mode rejection ratio (CMRR) of 140 dB. In order to cover PPW signals bandwidth,
a combination of a Butterworth high-pass filter (HPF) of 0.05 Hz and low pass filter (LPF) of 35 Hz
were implemented, according to Equations (6) and (7). Based on the analysis of hardware functionality,
sweeping frequencies from 10−3 Hz to 103 Hz were performed to evaluate the frequency response of
the front-end analog circuit. The simulation result performed the required bandwidth (0.05–35 Hz)
with an amplification factor of about 59.9 dB and obtained a lower cutoff frequency (fL ) of 0.05 Hz and
a higher cutoff frequency (fH ) of 35.12 Hz (Figure 5).

49.4KΩ
Gain = +1 (5)
RG

1
fHPF = √ (6)
2π R1 R2 C1 C2
1
fLPF = √ (7)
2π R3 R4 C3 C4

Figure 5. The simulated frequency response of the system.

3.3. Post-Processing Unit

A custom-designed software based on the LabVIEW platform was developed to analyze the PPW
signal in the post-processing unit. To extract the signals of the arterial pressure pulse, the respiration
signal removal was required to eliminate the baseline wandering by detrending the raw recording.
The signal denoise was important for peak and valley detection algorithm; therefore, the WA Denoise
VI function was implemented after the baseline wandering removal. In order to extract the peak and
valley points in PPW signals, a threshold detection method was provided (Figure 6). The voltage
information in SBP and DBP feature points was described (the solid lines are de-noise PPW signals,
and dashed lines are detection thresholds). The voltage change of SBP and DBP feature points within
adjacent PPW signals can be acquired, according to Equations (8) and (9). The pressure sensitivity
of the piezoelectric sensor offers a unit conversion of 2 mmV/mmHg that implies that the pressure
Sensors 2020, 20, 851 6 of 12

change is 0.5 mmHg per mV, according to Equation (10). Therefore, the pressure change of SBP and
DBP feature points between the adjacent PPW signals were obtained by (11).

∆mV 1 = V max,2 −V max,1 , ∆mV 2 = V max,3 −V max,2 , . . . (8)

∆mV a = V min,2 −V min,1 , ∆mV b = V min,3 −V min,2 , . . . (9)

2mV
Pressure sensitivity = (10)
mmHg
∆V × 1000
∆mmHg = ×(Pressure sensitivity)−1 (11)
Gain

3.4. Ethics Statement

The experiment was approved by the Institutional Review Board of National Chiao Tung University
(registration number: NCTU-REC-108-087E). Thirty subjects participated in the experiment (19 males
and 11 females, age 20–60 years, height 150–183 cm, weight 50–110 kg). They were healthy without
any known diseases and provided their written informed consent. They were asked to refrain from
alcohol, caffeine, and strenuous exercise for 1 h before the measurement. In the experiment, all subjects
consented to participate and were instructed to remain in a sitting position without movement to avoid
motion artifacts during the measurement.

Figure 6. Peak and valley detection algorithm for pressure pulse wave (PPW) signals.

4. Experimental results

4.1. Pressure Pulse Wave (PPW) Signals Analysis for Beat-to-Beat Systolic Blood Pressure (SBP) and Diastolic
Blood Pressure (DBP)
The piezoelectric sensor was placed on the skin above the radial artery and measured for 10 sec
to obtain the continuous pressure waveform. Figure 7a shows the continuous PPW signals obtained
from the analog circuit. In order to detect the exact locations of the peak and valley of PPW signals,
post-processing was performed to produce distinguishable feature points of SBP and DBP, as shown in
Figure 7b. Figure 8 shows that the peak and valley values were extracted from the continuous PPW
post-processing signals by the threshold method. Figure 9a indicates that the voltage change within
adjacent PPWs was calculated, according to Equations (8) and (9). The pressure change within adjacent
PPWs was obtained by conversion of pressure sensitivity (2 mV/mmHg) and circuit amplification
gain of 989, according to Equation (11). Therefore, the pressure change between adjacent beats can
be calculated, as shown in Figure 9b. The measurement strategy uses the sum of the initial blood
pressure by an oscillometric method and pressure change by a piezoelectric sensor to achieve the
Sensors 2020, 20, 851 7 of 12

beat-to-beat SBP and DBP monitoring, according to Equation (1). The initial SBP and DBP measured by
the cuff-method were respectively 109 mmHg and 61 mmHg. Figure 10 demonstrates the beat-to-beat
SBP and DBP monitoring.

Figure 7. PPW signals from the (a) analog circuit (b) post-processing unit.

Figure 8. Peak and valley detection algorithm for PPW signals.

Figure 9. (a) The voltage change and (b) pressure change within feature points of SBP and DBP.
Sensors 2020, 20, 851 8 of 12

Figure 10. Beat-to beat blood pressure for 12 beats.

4.2. Continuous Blood Pressure Measurement and Accuracy Evaluation

In order to perform accuracy evaluation compared to the oscillometric method, the left and
right hands of 30 subjects with the individual sensors were synchronously measured for 30 min. The
piezoelectric sensor was placed on the left hand to measure the continuously beat-to-beat pressure
change for 30 min. The oscillometric sensor was measured on the right hand at a regular interval of
1 min for 30 measurements in 30 min (Figure 11). The performance of our system was evaluated by
recording the MAE and standard deviation (SD) within two methods, according to Equations (12)
and (13).
n
1 X 
MAE = y −xi |
i
(12)
n
i=1
s
(y i −xi −MAE)2
Pn
i=1
SD = (13)
n−1
where xi is the reference blood pressure values obtained from the oscillometric sensor and yi is
the measurement blood pressure values obtained from our system on n measurements. Table 1
demonstrates the average MAE ± SD of SBP and DBP were 1.52 ± 0.30 mmHg and 1.83 ± 0.50 mmHg
for 30 subjects.

Figure 11. (a) PPW signals from the radial artery for 30 min measurement. (b) Accuracy evaluation for
a piezoelectric-base system for 30 min measurement, compared to an oscillometric sensor (Subject 1).
Sensors 2020, 20, 851 9 of 12

Table 1. Accuracy evaluation for our system.

Height Weight SBP Error DBP Error

Subject Male Age
(cm) (kg) (MAE ± SD mmHg) (MAE ± SD mmHg)
1 Male 58 180 90 1.34 ± 0.07 1.61 ± 0.16
2 Female 57 150 68 1.51 ± 0.13 1.92 ± 0.22
3 Male 60 170 80 1.46 ± 0.17 1.87 ± 0.29
4 Female 36 155 66 1.62 ± 0.21 2.01 ± 0.38
5 Male 31 168 65 1.24 ± 0.27 1.56 ± 0.39
6 Male 36 175 90 1.44 ± 0.33 1.64 ± 0.66
7 Male 27 175 68 1.47 ± 0.22 1.77 ± 0.52
8 Female 27 156 55 1.7 ± 0.42 2.06 ± 0.71
9 Female 24 160 90 1.39 ± 0.35 1.72 ± 0.66
10 Male 28 180 110 1.58 ± 0.44 1.95 ± 0.77
11 Male 36 176 105 1.22 ± 0.21 1.84 ± 0.51
12 Female 27 163 55 1.38 ± 0.19 1.79 ± 0.44
13 Female 27 164 61 1.66 ± 0.47 1.68 ± 0.41
14 Male 27 168 68 1.53 ± 0.38 1.72 ± 0.49
15 Male 27 165 79 1.47 ± 0.24 1.76 ± 0.39
16 Male 27 168 72 1.51 ± 0.26 1.89 ± 0.44
17 Male 27 170 68 1.42 ± 0.33 1.77 ± 0.46
18 Female 59 156 71 1.45 ± 0.22 1.87 ± 0.34
19 Female 54 154 50 1.38 ± 0.28 1.92 ± 0.44
20 Male 23 168 66 1.54 ± 0.36 1.86 ± 0.55
21 Male 27 163 62 1.58 ± 0.32 1.83 ± 0.51
22 Male 23 178 72 1.56 ± 0.28 1.78 ± 0.61
23 Male 20 173 68 1.33 ± 0.15 1.82 ± 0.53
24 Female 21 160 58 1.49 ± 0.24 1.79 ± 0.46
25 Female 27 160 54 1.62 ± 0.33 1.96 ± 0.61
26 Male 20 175 53 1.84 ± 0.37 1.77 ± 0.55
27 Male 20 174 105 1.58 ± 0.41 2.07 ± 0.66
28 Male 23 183 71 1.77 ± 0.55 1.88 ± 0.73
29 Male 20 170 85 1.67 ± 0.41 1.83 ± 0.55
30 Female 20 155 61 1.89 ± 0.43 1.88 ± 0.62
Average 1.52 ± 0.30 1.83 ± 0.50

5. Discussions

5.1. Measurement Strategy and Performance

This study developed a wearable piezoelectric-based system that uses the sum of the initial
blood pressure by an oscillometric method and pressure change by a piezoelectric sensor to obtain
the beat-to-beat SBP and DBP. The continuous PPW signals extracted from the radial artery by a
piezoelectric sensor directly reveals the arterial behaviors of expansion and contraction. The beat-to-beat
pressure change was obtained by the pressure sensitivity of the piezoelectric sensor (2 mV/mmHg). In
order to linearly convert the electrical signals to pressure signals by pressure sensitivity, the tested
signals must stay within the pressure range of the sensor in the specification. The ranges of SBP and
DBP are, respectively, from 70/40 mmHg and 190/100 mmHg, including categories of hypotension,
normal blood pressure, and hypertension. We used a piezoelectric sensor with a pressure range of
−50–3000 mmHg to ensure the system operation in the linear region; therefore, we believe that our
method can obtain correct blood pressure values in different cardiovascular diseases by the combined
evidence of sensor characteristics and experimental results. The experimental results indicated that
the reliable MAE ± SD for the SBP and DBP were 1.52 ± 0.30 mmHg and 1.83 ± 0.50 mmHg, which
agreed with the Association for the Advancement of Medical Instrumentation (AAMI) [21] and British
Hypertension Society (BHS) [22] standard criteria of MAE within 5 mmHg and SD within ±8 mmHg.
Therefore, this study demonstrates a novel measurement strategy that uses sensor properties to obtain
accurate beat-to-beat blood pressure recording without multiple calibrations and complex regression
analysis of the estimation model.
Sensors 2020, 20, 851 10 of 12

5.2. Accuracy Evaluation with Other Works

A summary of recent studies on continuous blood pressure measurement is shown in Table 2.
These works demonstrated the proposed technique with accuracy compared to cuff-sensor. Lazazzera
et al. [9] presented a smartwatch of CareUp®(Farasha Labs, Paris, France) for blood pressure estimation
that uses the ECG and PPG physiological channels to calculate the PTT and estimate the blood pressure
by a linear model. The experimental results indicated that the MAE ± SD for SBP and DBP were
validated by a sphygmomanometer, and obtained 1.52 ± 9.45 mmHg and 0.39 ± 4.93 mmHg on 44
subjects. Slapniˇcar et al. [10] created a blood pressure estimation model by PPG measurement and
deep neural network. The results obtained MAE for SBP and DBP were, respectively, 9.43 and 6.88.
Simjanoska et al. [23] provided a machine learning model to estimate the blood pressure from ECG
recording on 51 different subjects and obtained MAE ± SD for SBP and DBP were 7.72 ± 10.22 mmHg
and 9.45 ± 10.03 mmHg. Wang et al. [24] used PPW and PPG wave to calculate the PTT and established
the blood pressure estimation model and resulted in an accuracy of 3.71 ± 3.06 mmHg for SBP and 5.44
± 5.10 mmHg for DBP. Liu et al. [25] used impedance plethysmography (IPG) technique to establish
SBP model by linear regression and obtained the correlation coefficient of 0.7 with a cuff method. Liu
et al. [17] provided a multiparameter fusion (MPF) estimation model that combined 21 features of PPW
and computed the summation of 21 features of PPW for blood pressure estimation. The PPW-based
mathematical model was used for further comparative analysis with the best PTT-based model and
obtained the excellent estimation error of 0.7 ± 7.78 mmHg for SBP, and 0.83 ± 5.45 mmHg for DBP,
compared to the PTT-based model of 1.33 ± 0.37 mmHg and 1.14 ± 0.20 mmHg for SBP and DBP.

Table 2. Recent works for blood pressure measurement.

Statistic SBP Error DBP Error

Author Technique Ref.
Method (mmHg) (mmHg)
Lazazzera PTTECG. PPG MAE ± SD 1.52 ± 9.45 0.39 ± 4.93 [9]
Simjanoska PTTECG MAE ± SD 7.72 ± 10.22 9.45 ± 10.03 [23]
Slapniˇcar PTTPPG MAE 9.43 6.88 [10]
Wang PTTPPW, PPG MAE ± SD 3.71 ± 3.06 5.44 ± 5.10 [24]
Correlation
Liu PTTIPG 0.7 - [25]
coefficient
Liu PPWEstimation model MAE ± SD 0.70 ± 7.78 0.83 ± 5.43 [17]
Our work PPWPressure change MAE ± SD 1.52 ± 0.30 1.83 ± 0.50 -

Compared to the above studies, we demonstrated a low-cost and accurate continuous beat-to-beat
SBP/DBP detection system requiring fewer PPW features. Importantly, our system could obtain a
qualified accuracy of MAE within 2 mmHg and SD within ± 1 mmHg without the need for multiple
calibrations and complex regressions. We believe that our method is novel in that it is a step further
than the previous studies.

5.3. Limitation
We used a straightforward method to convert voltage changes to pressure changes in PPW signals
directly by piezoelectric properties of pressure sensitivity. However, stable PPW signals from the radial
artery remain a significant issue that can also be affected by daily activities such as muscle changes
caused by walking, eating, dressing, grabbing, etc. Our study used a solid piezoelectric sensor with an
analog front-end to validate the direct estimation concept with the scope of measurement in the resting
condition lasting for up to 30 min. No doubt, the solid structure of the piezoelectric sensor could
easily induce air gaps under extended use during daily activities. In our future work, we expect to (1)
improve the design of flexible piezoelectric sensors, and optimized analog frontend construction may
more appropriately address this important aspect in ambulatory blood pressure measurement, and
Sensors 2020, 20, 851 11 of 12

(2) recruit more participants, especially patients with blood pressure problems, to make our method
more reliable.

6. Conclusions
This paper develops a low-cost piezoelectric-based system to validate a straightforward
computation for continuous beat-to-beat blood pressure measurement. The method uses the summation
of initial blood pressure and pressure change without the need for calculating correlation and repeated
calibrations. We estimated the continuous beat-to-beat blood pressure using the pressure sensitivity of
the piezoelectric sensor to directly convert the voltage difference between adjacent systolic and diastolic
feature points in PPW into pressure difference. The experimental results indicated our system produced
a reliable accuracy of SBP (MAE ± SD 1.52 ± 0.30 mmHg) and DBP (MAE ± SD 1.83 ± 0.50 mmHg),
which agreed with the AAMI of MAE within 5 mmHg and SD within ± 8 mmHg. Overall, this
study developed a low-cost wearable piezoelectric-based system using an intuitive measurement
strategy with qualified accuracy. The new system is potentially suitable for continuous long-term
blood pressure-monitoring applications.

Author Contributions: T.-W.W. conceived of the presented idea, carried out the experiment and wrote the
manuscript. S.-F.L. supervised the project. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Kitterman, J.A.; Phibbs, R.H.; Tooley, W.H. Catheterization of umbilical vessels in newborn infants. Pediatr.
Clin. N. Am. 1970, 17, 895–912. [CrossRef]
2. Chen, S.; Ji, Z.; Wu, H.; Xu, Y. A Non-Invasive Continuous Blood Pressure Estimation Approach Based on
Machine Learning. Sensors 2019, 19, 2585. [CrossRef] [PubMed]
3. Goli, S.; Jayanthi, T. Cuff less continuous non-invasive blood pressure measurement using pulse transit time
measurement. Int. J. Recent Dev. Eng. Technol. 2014, 2, 16–86.
4. Choi, Y.; Zhang, Q.; Ko, S. Noninvasive cuffless blood pressure estimation using pulse transit time and
Hilbert–Huang transform. Comput. Electr. Eng. 2013, 39, 103–111. [CrossRef]
5. Nye, E. The effect of blood pressure alteration on the pulse wave velocity. Br. Heart J. 1964, 26, 261. [CrossRef]
6. Gribbin, B.; Steptoe, A.; Sleight, P. Pulse wave velocity as a measure of blood pressure change. Psychophysiology
1976, 13, 86–90. [CrossRef]
7. Chen, W.; Kobayashi, T.; Ichikawa, S.; Takeuchi, Y.; Togawa, T. Continuous estimation of systolic blood
pressure using the pulse arrival time and intermittent calibration. Med. Biol. Eng. Comput. 2000, 38, 569–574.
[CrossRef]
8. Peter, L.; Noury, N.; Cerny, M. A review of methods for non-invasive and continuous blood pressure
monitoring: Pulse transit time method is promising? Irbm 2014, 35, 271–282. [CrossRef]
9. Lazazzera, R.; Belhaj, Y.; Carrault, G. A New Wearable Device for Blood Pressure Estimation Using
Photoplethysmogram. Sensors 2019, 19, 2557. [CrossRef]
10. Slapničar, G.; Mlakar, N.; Luštrek, M. Blood Pressure Estimation from Photoplethysmogram Using a
Spectro-Temporal Deep Neural Network. Sensors 2019, 19, 3420. [CrossRef]
11. Sharma, M.; Barbosa, K.; Ho, V.; Griggs, D.; Ghirmai, T.; Krishnan, S.; Hsiai, T.; Chiao, J.-C.; Cao, H. Cuff-less
and continuous blood pressure monitoring: A methodological review. Technologies 2017, 5, 21. [CrossRef]
12. Proença, J.; Muehlsteff, J.; Aubert, X.; Carvalho, P. Is pulse transit time a good indicator of blood pressure
changes during short physical exercise in a young population? In Proceedings of the International Conference
of the IEEE Engineering in Medicine and Biology Society, Buenos Aires, Argentina, 31 August–4 September
2010.
Sensors 2020, 20, 851 12 of 12

13. Wong, M.Y.-M.; Poon, C.C.-Y.; Zhang, Y.-T. An evaluation of the cuffless blood pressure estimation based on
pulse transit time technique: A half year study on normotensive subjects. Cardiovasc. Eng. 2009, 9, 32–38.
[CrossRef] [PubMed]
14. Fung, P.; Dumont, G.; Ries, C.; Mott, C.; Ansermino, M. Continuous noninvasive blood pressure measurement
by pulse transit time. In Proceedings of the International Conference of the IEEE Engineering in Medicine
and Biology Society, San Francisco, CA, USA, 1–5 September 2004.
15. Mase, M.; Mattei, W.; Cucino, R.; Faes, L.; Nollo, G. Feasibility of cuff-free measurement of systolic and
diastolic arterial blood pressure. J. Electrocarsiol. 2011, 44, 201–207. [CrossRef] [PubMed]
16. Kim, J.; Chou, E.F.; Le, J.; Wong, S.; Chu, M.; Khine, M. Soft Wearable Pressure Sensors for Beat-to-Beat Blood
Pressure Monitoring. Adv. Healthc. Mater. 2019, 8, 1900109. [CrossRef] [PubMed]
17. Liu, Z.-D.; Liu, J.-K.; Wen, B.; He, Q.-Y.; Li, Y.; Miao, F. Cuffless Blood Pressure Estimation Using Pressure
Pulse Wave Signals. Sensors 2018, 18, 4227. [CrossRef]
18. Kaisti, M.; Panula, T.; Leppänen, J.; Punkkinen, R.; Tadi, M.J.; Vasankari, T.; Jaakkola, S.; Kiviniemi, T.;
Airaksinen, J.; Kostiainen, P. Clinical assessment of a non-invasive wearable MEMS pressure sensor array for
monitoring of arterial pulse waveform, heart rate and detection of atrial fibrillation. NPJ Digit. Med. 2019, 2,
39. [CrossRef]
19. Spinelli, E.M.; Pallàs-Areny, R.; Mayosky, M.A. AC-coupled front-end for biopotential measurements. IEEE
T. Bio Med. Eng. 2003, 50, 391–395. [CrossRef]
20. Çakar, H.İ.; Kara, S.; Toker, O. Design of a Portable Electromyography Device for Back Herniated Patients. In
Proceedings of the International Conference on Biomedical Electronics and Devices, Valencia, Spain, 20–23
January 2010.
21. White, W.B.; Berson, A.S.; Robbins, C.; Jamieson, M.J.; Prisant, L.M.; Roccella, E.; Sheps, S.G. National
standard for measurement of resting and ambulatory blood pressures with automated sphygmomanometers.
Hypertension 1993, 21, 504–509. [CrossRef]
22. O’Brien, E.; Petrie, J.; Littler, W.; de Swiet, M.; Padfield, P.L.; Altman, D.; Bland, M.; Coats, A.; Atkins, N. The
British Hypertension Society protocol for the evaluation of blood pressure measuring devices. J. Hypertens
1993, 11, S43–S62.
23. Simjanoska, M.; Gjoreski, M.; Gams, M.; Madevska Bogdanova, A. Non-invasive blood pressure estimation
from ECG using machine learning techniques. Sensors 2018, 18, 1160. [CrossRef]
24. Wang, Y.-J.; Chen, C.-H.; Sue, C.-Y.; Lu, W.-H.; Chiou, Y.-H. Estimation of Blood Pressure in the Radial Artery
Using Strain-Based Pulse Wave and Photoplethysmography Sensors. Micromachines 2018, 9, 556. [CrossRef]
[PubMed]
25. Liu, S.-H.; Cheng, D.-C.; Su, C.-H. A cuffless blood pressure measurement based on the impedance
plethysmography technique. Sensors 2017, 17, 1176. [CrossRef] [PubMed]

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