SCIENCE TRANSLATIONAL MEDICINE | RESEARCH ARTICLE

CARDIOVASCULAR HEALTH Copyright © 2018

The Authors, some

Smartphone-based blood pressure monitoring via rights reserved;

exclusive licensee
the oscillometric finger-pressing method American Association
for the Advancement
of Science. No claim
Anand Chandrasekhar,1 Chang-Sei Kim,2,3 Mohammed Naji,1 Keerthana Natarajan,1 to original U.S.
Jin-Oh Hahn,2 Ramakrishna Mukkamala1* Government Works

High blood pressure (BP) is a major cardiovascular risk factor that is treatable, yet hypertension awareness and control
rates are low. Ubiquitous BP monitoring technology could improve hypertension management, but existing devices
require an inflatable cuff and are not compatible with such anytime, anywhere measurement of BP. We extended the
oscillometric principle, which is used by most automatic cuff devices, to develop a cuff-less BP monitoring device
using a smartphone. As the user presses her/his finger against the smartphone, the external pressure of the
underlying artery is steadily increased while the phone measures the applied pressure and resulting variable-
amplitude blood volume oscillations. A smartphone application provides visual feedback to guide the amount of pres-
sure applied over time via the finger pressing and computes systolic and diastolic BP from the measurements. We
prospectively tested the smartphone-based device for real-time BP monitoring in human subjects to evaluate usabil-

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ity (n = 30) and accuracy against a standard automatic cuff-based device (n = 32). We likewise tested a finger cuff
device, which uses the volume-clamp method of BP detection. About 90% of the users learned the finger actuation
required by the smartphone-based device after one or two practice trials. The device yielded bias and precision errors
of 3.3 and 8.8 mmHg for systolic BP and −5.6 and 7.7 mmHg for diastolic BP over a 40 to 50 mmHg range of BP. These
errors were comparable to the finger cuff device. Cuff-less and calibration-free monitoring of systolic and diastolic BP
may be feasible via a smartphone.

INTRODUCTION formed via finger actuation and can measure BP with accuracy similar
High blood pressure (BP) is a major risk factor for strokes and heart to the finger cuff device.
disease (1) that is treatable with lifestyle changes and medication (2).
However, hypertension awareness and control rates are low (3). Only
~55% of hypertensives in developed nations and ~45% of hyperten- RESULTS
sives in developing nations are aware of their condition, and ~15% Smartphone-based BP measurement device:
of hypertensives have their BP under control. Ubiquitous BP monitor- Concept, prototype, and usage
ing technology could improve hypertension awareness by providing Concept
serial measurements from the mass population during daily life (4) The smartphone-based device represents an extension of the oscillo-
and enhance hypertension control by providing continual feedback metric principle for cuff-less BP monitoring. As shown in Fig. 1A, in
to the individual patient (5). However, existing noninvasive devices re- conventional oscillometry, the cuff serves as an actuator to vary the ex-
quire an inflatable cuff and therefore are not feasible for such anytime, ternal pressure of an artery and as a sensor to measure this pressure and
anywhere monitoring of BP. the resulting variable-amplitude blood volume oscillations within the
We proposed to extend the oscillometric principle, which is the basis artery. BP is then computed from the oscillation amplitudes as a
of most automatic cuff-based BP measurement devices (6, 7), for cuff- function of the applied pressure (henceforth called the “oscillogram”).
less BP measurement using a smartphone. In this scenario, the user As shown in Fig. 1B, for the smartphone-based device, the user serves as
serves as the actuator (instead of the cuff) by pressing her/his finger the actuator by pressing her/his finger against the phone to steadily in-
against the phone to vary the external pressure of the underlying artery, crease the external pressure of the underlying artery (transverse palmar
whereas the phone serves as the sensor (rather than the cuff) to measure arch artery), whereas the phone, embedded with photoplethysmogra-
the resulting variable-amplitude blood volume variations or oscillations phy (PPG) and force transducers, serves as the sensor to measure the
and applied pressure. The phone also provides visual feedback to guide blood volume oscillations and applied pressure. PPG is a well-known
the amount of finger pressure applied over time and computes BP from optical technique in which a tissue sample is illuminated and the
the measurements. changes mainly in light absorption due to the pulsatile blood volume
To investigate the oscillometric finger-pressing method, we devel- within the tissue are measured (9). The phone also provides visual
oped a smartphone-based device to implement the method in real time. feedback to guide the amount of finger pressure applied over time, as
We then prospectively tested the device in human subjects for usability shown in Fig. 1C, and then likewise computes BP from the oscillogram,
and accuracy against a standard cuff device. We likewise tested a finger as shown in Fig. 1D.
cuff device, which uses the volume-clamp method, to determine BP (8). Prototype
Our results indicate that smartphone-based BP monitoring is easily per- Figure 2 (A and B) shows the smartphone-based device. The prototype
device is a three-dimensional (3D)–printed case affixed to the back of a
1
Department of Electrical and Computer Engineering, Michigan State University, smartphone. The case houses a PPG sensor on top of a force transducer
East Lansing, MI 48824, USA. 2Department of Mechanical Engineering, University to measure the blood volume oscillations and applied finger pressure,
of Maryland, College Park, MD 20742, USA. 3School of Mechanical Engineering,
Chonnam National University, Gwangju 61186, South Korea. as well as circuitry to acquire and transmit the measurements to the
*Corresponding author. Email: [email protected] smartphone (Fig. 2A). The smartphone runs an application to visually

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Usage
As shown in Fig. 2 (C to E), a user inter-
acts with the device to measure BP in
three steps. First, the user places her/his
index finger on the sensor so that the base
of the finger nail is aligned with “line 1”
on the back of the phone and that the long
axis of the finger is centered on “line 2”
(Fig. 2C). In this way, measurement from
the transverse palmar arch artery may be
targeted (Fig. 1B). The user also rests a
portion of the same finger below the top
knuckle on the case surface to ensure force
application in the normal direction rela-
tive to this surface (Fig. 2D). Second, the
user holds the device at the same height
as the heart to eliminate hydrostatic ef-

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fects while viewing the smartphone screen
(Fig. 2E). Third, the user presses her/his
finger against the sensor to steadily in-
crease the external pressure of the artery,
such that the external pressure application
acts similar to a cuff to press the artery
against the supporting bone (Fig. 1C).
The user maintains the applied pressure
within the target blue lines: Pressure is
displayed as it evolves in real time via
the smartphone application (Fig. 2B). Af-
ter sufficient finger pressure is achieved,
the measurement automatically termi-
nates, and the BP measurements are dis-
played. If the applied pressure falls outside
the target lines or the oscillogram quality
is deemed inadequate due to a measure-
ment or computation failure, then the de-
vice asks the user to try again. See movie
S1 for a video demonstration of the device.

Device testing:
Usability and accuracy
Usability
To test device usability, 30 new users (age,
39 ± 10 years; height, 168 ± 8 cm; weight,
79 ± 18 kg; 67% females) participated.
Each user was allowed practice trials
to learn the finger actuation procedure.
Figure 3A shows a histogram of the num-
Fig. 1. From conventional cuff-based blood pressure measurement to cuff-less BP monitoring using a smart- ber of practice trials required for each user
phone. (A) Image of a conventional cuff-based oscillometric device and diagram of representative blood pressure to correctly execute the finger actuation,
(BP) measurement. (B) Schematic diagrams of the proposed oscillometric finger-pressing method for cuff-less BP
maintaining the applied finger pressure
monitoring using a smartphone, in which the user serves as the actuator instead of the cuff, to vary the external
within the target blue lines on the smart-
pressure of the transverse palmar arch artery by finger pressing, whereas the phone serves as the sensor to measure
blood volume oscillations and applied pressure similar to a cuff, provides a visual display of the applied finger
phone application. About 90% of the users
pressure over time to guide the actuation (C), and computes BP similar to a cuff (D). Image of finger anatomy learned the finger actuation after one or
adapted from (35). two trials. After learning the finger actua-
tion, each user then performed the finger
actuation two to four times with the aim
guide the finger actuation and compute systolic, diastolic, and mean of obtaining a pair of close or three BP measurements. Figure 3B shows
BP at the brachial artery from the finger blood volume oscillation and a histogram of the output of the device (BP measurement or “try again”
finger pressure measurements (Fig. 2B). message) overall measurements. About 60% of the measurements were

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Accuracy
To test device accuracy, the same 30 new
users and 5 additional experienced users
(age, 33 ± 8 years; height, 173 ± 4 cm;
weight, 72 ± 5 kg; 0% females) partici-
pated. The latter five users also obtained
multiple BP measurements but held the
device well below the heart to raise their
BP. Device measurements during this hy-
drostatic challenge may be thought of as
BP from a brachial artery situated beneath
the heart. The BP measurements from the
device were averaged when more than one
measurement was available and were as-
sessed against the average of two mea-
surements from a standard oscillometric
arm cuff device. Figure 4 (A to D) shows

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the correlation and Bland-Altman plots
for the systolic and diastolic BP mea-
surements from the 32 users for which
the smartphone-based device yielded
BP measurements, and the reference
device produced valid BP values. The
smartphone-based device yielded bias
errors (m) and precision errors (s) of 3.3
and 8.8 mmHg for systolic BP and −5.6
and 7.7 mmHg for diastolic BP over a
40- to 50-mmHg range of BP. Figure 4
(E to H) shows corresponding plots for a
finger cuff device, which uses the volume-
clamp method and likewise computes
brachial BP from finger measurements.
The smartphone-based device showed
BP measurement accuracy similar to the
finger cuff device with respect to the stan-
dard arm cuff device. However, unlike
the smartphone-based device, the finger
cuff device always yielded BP measure-
ments. Table S1 shows the individual
Fig. 2. Smartphone-based device for real-time monitoring of BP via the oscillometric finger-pressing method. subject-level results of the device testing,
(A) Photograph of the smartphone-based device. A three-dimensional (3D)–printed case was affixed to the back of a including anthropomorphic information,
smartphone. The case includes visual line indicators to guide finger placement and houses photoplethysmography number of practice trials, and all of the BP
(PPG) and force sensors along with other circuitry to acquire and transmit the finger blood volume oscillation and measurements.
applied finger pressure measurements to the phone. (B) Photograph of an application running on the phone to pro-
vide visual guidance for the finger actuation and display the finger measurements. Photographs illustrating that a user
places her/his finger on the sensor according to the line indicators (C), rests the same finger on the surface of the case
DISCUSSION
to apply force in the normal direction with respect to the case (D), and holds the device at the same height as the heart (E).
We proposed the oscillometric finger-
pressing method for cuff-less BP monitor-
successful. Figure 3C shows a histogram of the number of try again mes- ing using a smartphone. This method may be implemented with a PPG
sages outputted by the device for each user. The device did not output a sensor, which measures pulsatile blood volume (9), and a force sensor.
try again for about 50% of the users and yielded multiple BP measure- These sensors are already integrated in many smartphones (10, 11), al-
ments for about 80% of the users. However, the device did not output though some customization of the sensor architecture is necessary to
any BP measurements for 2 of the 30 users. Figure 3D shows a histo- enable BP measurements. Because the user serves as the actuator to ap-
gram of the reasons for the try again messages. Almost 60% of the try ply external pressure to the transverse palmer arch artery in her/his
again messages were due to a computation failure. The remaining try index finger, the requisite hardware that performs BP measurements
again messages were almost exclusively due to a measurement failure. is miniaturized and greatly simplified compared to possible alternative
Actuation failure was rare. Computation failure is relatively easy to cor- methods that would automatically vary the external pressure. Therefore,
rect and was the reason that the device did not produce any BP mea- it may be relatively easy to incorporate the components required by the
surement in one of the users. oscillometric finger-pressing method in smartphone encasings, which

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PTT often varies inversely with BP in a person and can be measured

simply as the relative timing between proximal and distal waveforms
indicative of the arterial pulse. Hence, PTT could potentially permit
convenient BP monitoring. However, PTT in units of milliseconds must
be calibrated to BP in units of millimeters of mercury, and PTT, as a
single value, cannot independently track systolic and diastolic BP. As
a result, accuracy is the concern for the PTT-based approach. Ultra-
sound may allow for other methods. The most popular ultrasound
method measures the arterial diameter waveform along with the lo-
cal PTT (in the form of pulse wave velocity) and then applies the
Bramwell-Hill equation to compute the absolute pulse pressure (sys-
tolic BP-diastolic BP) (12–14). Diastolic BP may also be measured
via calibration of the PTT measurement. However, convenience is gen-
erally the concern for ultrasound systems. Arterial tonometry is a long-
standing method (15) also worth mentioning. In theory, this method
can measure a BP waveform without using a cuff by pressing a force
sensor on an artery. The sensor must flatten or applanate the artery so

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that its wall tension is perpendicular to the probe. However, manual
applanation and automatic applanation have proven to be difficult,
so the measured waveform is routinely calibrated with cuff BP values
in practice (16).
The oscillometric finger-pressing method may overcome the short-
comings of other cuff-less BP measurement modalities. First, it can in-
dependently measure systolic and diastolic BP without any calibration
and may therefore be sufficiently accurate. Second, it offers a con-
venience advantage over automatic cuff devices: People in low-resource
settings may not have any access to cuff devices; others must go to
pharmacies or other specified locations to use these devices; and people
who own a device are unlikely to carry it with them wherever they go. By
contrast, smartphones are readily available to many. About 3 billion
people around the world are predicted to have smartphones by 2020
(17). It is also anticipated that smartphones will become widely used
in low-income nations in the near future due to reduced costs resulting
from more competition in the marketplace (18). Furthermore, smart-
phones are constantly in use. For example, adults in the U.S. use these
devices almost 3 hours a day on average (19).
An oscillometric method for cuff-less BP monitoring was previously
proposed and was demonstrated in a pilot subject (20). In that study, a
person raised her/his hand to lower the transmural pressure of the hand
arteries via the hydrostatic effect while wearing a ring embedded with
PPG and force sensors on a finger to measure the resulting variable-
amplitude blood volume oscillations and the pressure applied by the
ring on the finger. The main concern with this interesting method is
that the extent of the pressure reduction is limited by the arm length.
Hence, for most people, the ring must be applied on the finger at a
pressure that does not deviate considerably from the mean BP of
the person so that the oscillogram may be interrogated over the crucial
Fig. 3. Device usability results (n = 30 new users). Histograms of the (A) number zero–transmural pressure regime. Furthermore, extra sensors for
of practice trials needed to learn the requisite finger actuation for all users; (B) per- measuring the height of the hand relative to the heart are required, or
centage of BP measurements versus try again messages outputted by the device assumptions about the relative height must be made; motion artifact
over all users; (C) number of try again messages per user; and (D) reasons for the try
may be problematic when the hand raising is performed relatively
again messages.
quickly, or smooth muscle contraction may be a factor when the hand
raising is performed very slowly (15); and hand-raising may be awk-
are commonly used to protect the phone against damage due to drops ward for users in public settings. The proposed oscillometric finger-
and otherwise or within the phones themselves. For example, a thin- pressing method overcomes these limitations, although it is vulnerable
filmed force sensor could be placed on top of an existing PPG sensor to BP measurement error when the device is not held at the same height
on the back of the phone. as the heart.
Other cuff-less BP measurement modalities are being widely pursued We developed a smartphone-based device to implement the oscil-
at present. Pulse transit time (PTT) is the most popular method (9). lometric finger-pressing method in real time. The prototype device

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tolic and diastolic BP at the brachial artery

from the finger measurements. It is BP at
the brachial artery rather than the finger
that is the proven cardiovascular risk fac-
tor (1). The device outputs a try again mes-
sage if the actuation is unsuccessful or the
oscillogram quality is deemed inadequate.
We tested the usability of the device and
its accuracy against a standard automatic
arm cuff device in 35 human subjects while
likewise assessing a finger cuff device often
used in research that has achieved approv-
al from the U.S. Food and Drug Adminis-
tration for measuring brachial BP (21). This
finger cuff device applied the volume-
clamp method as follows. First, the finger
cuff device slowly increases the cuff pres-

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sure while also measuring the blood vol-
ume via a PPG sensor within the cuff to
compute mean BP according to the oscil-
lometric principle. Then, the device contin-
ually varies the cuff pressure to maintain
the “unloaded” blood volume (the blood
volume at which the cuff pressure equals
the mean BP) throughout the cardiac cy-
cle via a fast servo-control system. The cuff
pressure may therefore yield the finger BP
waveform. This BP waveform is then
converted to a brachial BP waveform via
an empirical algorithm (22).
We found that all new users could
execute the finger actuation required by
the smartphone-based device and that
most of these users could do so after one
or two practice trials. We suspect that the
finger actuation becomes second nature
with increasing device usage. After the
new users learned the finger actuation,
the device yielded BP measurements much
more often than not. When the device
produced the try again messages, the
cause was usually due to computation
and measurement failures rather than ac-
tuation failure. Computation failures may
be easily corrected in the future as more
data are collected and with software up-
dates. It may also be possible to reduce
the frequency of try again errors due to
Fig. 4. Device accuracy results (n = 32 users). Correlation and Bland-Altman plots comparing the brachial BP
measurement failure without compro-
measurements from the smartphone-based device [oscillometric finger-pressing method (A to D)] and the brachial
BP measurements from a finger cuff device [volume-clamp method (E to H)], with each relative to a standard arm
mising accuracy by lowering the standard
cuff device. The filled circles are data points from new users holding both finger devices at the same height as the for measurement quality. Although the
heart, whereas the unfilled circles are data points from experienced users holding both finger devices below the device did not yield BP measurements
heart to raise the BP. r, correlation coefficient; m, bias error (mean of the errors); s, precision error (SD of the errors); in two users, the reason was computation
solid line in Bland-Altman plots, bias error; dashed lines in Bland-Altman plots, limits of agreement. failure for one of the users (and measure-
ment failure for the other user).
The smartphone-based device could
includes a PPG and a force sensor unit to acquire the requisite measure- measure systolic and diastolic BP with promising accuracy. The device
ments from the finger, a visual display on a smartphone application to yielded bias and precision errors relative to the automatic arm cuff de-
guide the finger actuation, and an empirical algorithm to compute sys- vice that were close to the AAMI (Association for the Advancement of

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Fig. 5. Smartphone-based device hardware. Schematic diagram of the PPG and force sensor unit and photograph of this unit, data acquisition and transmission
circuitry, and power supply housed within the 3D-printed case affixed to the back of the phone. IR, infrared; LED, light-emitting diode; PD, photodetector; ADC, analog-
to-digital converter; BLE, Bluetooth low energy.

Medical Instrumentation) limits of 5 and 8 mmHg, but an AAMI data even cuff-based methods may not be suitable for everyone (for example,
collection protocol was not used. Furthermore, the device measured BP morbidly obese people). Another limitation is that the smartphone-
as accurately as the finger cuff device. based device was not tested according to an AAMI data collection
Here, all of the subjects used the device correctly. In practice, users protocol, which involves a subject population that covers a prescribed
may not always be so compliant. However, a key advantage of a range of BP values (28). However, by also studying experienced users
smartphone-based BP monitoring device is that many measurements during a hydrostatic challenge, we were able to extend the tested range
can be made over time with the ubiquitous system (23). These measure- of each BP measurement to 40 to 50 mmHg. The device may be im-
ments could be averaged to eliminate error caused by random variations proved by leveraging additional sensing to confirm correct device usage,
in finger placement on the sensor and in the height at which the device by mitigating the adverse effect of finger vascular tone changes via in-
is held, as well as to mitigate error caused by imperfect BP computation. clusion of a temperature sensor to assess cold-induced finger vaso-
Averaging many measurements also abolishes the substantial BP constriction, or by applying a physics-based algorithm to compute
variations that occur within a person due to stress, physical activity, re- both BP and the arterial compliance curve (rather than an empirical al-
cent ingestion of a meal, and other factors (24). In this way, the device gorithm, which may implicitly assume invariant arterial compliance
may be able to indicate a sufficiently reliable BP measurement for hy- curves despite finger vascular tone changes) (29). The smartphone
pertension detection despite large errors in any single measurement. could also warn users of high BP, securely transmit the measured BP
Screening for hypertension may be the main clinical application of to caregivers, and send text reminders to patients with uncontrolled
the device, especially in the 20- to 50-year-old segment of the population BP to take their medications.
who are often technology savvy and health conscious but may be at risk In summary, we studied the oscillometric finger-pressing method
for early development of hypertension (25, 26). for cuff-less BP monitoring using a smartphone. Although various form
Our study has limitations, and future efforts are needed to bring the factors for implementing this method may be envisaged, the smart-
oscillometric finger-pressing method to practice. One limitation is that phone form may allow the method to reach the most people while being
the oscillometric finger-pressing method can neither make nighttime conveniently housed within a single, portable device. In this way, a com-
BP measurements, which are clinically important (27), nor be per- plete hypertension management system would be available in the pockets
formed by all people, such as those lacking fine motor control. However, of many.

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Fig. 6. Smartphone-based device software. Flowchart of the smartphone application and important equations for computing BP running on the phone wherein the
input is the measured blood volume waveform and applied pressure and the output is brachial BP values or a try again message. The blue box indicates the beginning
of the flowchart, whereas the red boxes indicate the two possible ends of the flowchart. The plot illustrates a parametric model of the oscillogram [blood volume
oscillation amplitude (y) as a function of the applied finger pressure (x)] from which BP is computed. BP computation details are provided in the “Software” subsection
of Materials and Methods.

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cuff BP measurements. This study included

the following predefined components:
number of subjects (n = 35) that is about
half of the AAMI study population (28)
and comparable to similar studies in the
field for demonstrating proof of concept
(9); number of measurements per subject;
and subject and data inclusion/exclusion
criteria. No outliers were excluded.

Device development:
Informal human study
To develop the hardware component of
the device and a basic visual display for
finger actuation guidance, we qualitatively
explored various options in about 10 hu-
man subjects. We then collected a training

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data set to define the software component
of this device, including finger measure-
ments, via the device held at the same
height as the heart and reference BP mea-
surements via a standard automatic arm
cuff (BP7650N, Omron) from 31 human
subjects (age, 31 ± 7 years; height, 170 ±
8 cm; weight, 68 ± 10 kg; 39% females).
Reference systolic and diastolic BP in this
data set ranged from 90 to 124 mmHg and
60 to 89 mmHg, respectively. We com-
puted reference mean BP, which was not
outputted by the automatic arm cuff de-
vice, from systolic and diastolic BP accord-
ing to the 0.4/0.6 rule (30).

Device development: Prototype

Hardware
We built a physical device consisting of
Fig. 7. Human study design for device testing. Photographs of the three BP measurement devices for study: a 3D-printed case attached to a smart-
(A) the smartphone-based device, (B) a standard automatic arm cuff device (the reference device), and (C) a finger cuff phone. The case (Vero White material;
device (a competing device). (D) Diagram of the experimental protocol for BP measurement using the devices shown 112 mm × 68 mm × 11.6 mm dimensions;
in (A) to (C). The protocol included a learning phase for new users to become familiar with the smartphone-based printed by Objet350 Connex, Stratasys)
device and a data collection phase involving a measurement with the reference device, two to four measurements was attached using screws to the back
with the smartphone-based device, 1 min of measurement with the finger cuff device, and a final measurement with of a standard smartphone encasing
the reference device. Study details are provided in the “Device testing: Formal human study” subsection of Materials
(SAMS6HPCTUFF2DIM1, MyBat),
and Methods.
which housed the smartphone (Galaxy
S6, Samsung). The components within
MATERIALS AND METHODS the case include a sensor unit, data acquisition and transmission
Study design circuitry, and a power supply, as shown in Fig. 5. The sensor unit con-
We investigated the oscillometric finger-pressing method for cuff-less sists of PPG and force transducers. The PPG sensor was custom-built,
BP monitoring using a smartphone. We performed informal and for- comprising a light-emitting diode and photodetector pair operating in
mal human studies under protocols approved by the Michigan State reflectance-mode and at an infrared wavelength (940 nm) to penetrate
University Institutional Review Board and with written, informed con- beneath the skin (9) and to provide superior signal quality in lower–skin
sent from each subject. The informal study facilitated the development perfusion conditions (dark skin pigmentations and cold temperatures)
of a single prototype device, whereas the formal study allowed for ob- (31). The sensor surface, which constitutes the finger pressing area, is a
jective testing of this device. The formal study followed a prospective 10-mm-diameter circle. The force sensor (CS15-4.5N, SingleTact) is a
design, in which the real-time output of the device was assessed (as thin-filmed, capacitive transducer that measures normal direction force,
opposed to a retrospective design in which an offline output, as de- with specifications congruent with BP measurement (0.9-mmHg reso-
termined by first recording the finger blood volume oscillation and lution and 430-mmHg range). The force-sensitive area is a 15-mm-
pressure measurements of the device and then analyzing the measure- diameter circle. The PPG sensor is positioned on top of the force sensor
ments, is assessed). The study was therefore necessarily blinded to all with a rigid-structure-rubber sheet (TangoBlack material; 15 mm diameter)

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between the two, which allows the force applied on the PPG sensor, but and the local maxima of the waveform. Because the PPG sensor mea-
not elsewhere on the case surface, to reach the force-sensitive area and sures a differentiated blood volume waveform, the waveform peaks are
be uniformly distributed on it. A one-time calibration of the force sensor reflective of the peak-to-peak amplitudes of the blood volume oscilla-
was performed while residing in the completed case via placement of tions. If the average of the reciprocal of the peak-to-peak intervals is not
high-density weights (WHST13, United Scientific Supplies) on the within 10% of the average heart rate determined via spectral analysis (in
PPG sensor. The relationship from the voltage (V) measured by the hertz), then the application will ask the user to try again because the
force sensor to the known pressure (P, the force exerted by each weight blood volume waveform may be contaminated by artifact or the wave-
divided by the area of a 10-mm-diameter circle) was represented with a form beats may not have been well detected. The applied pressure mea-
piece-wise linear function (P = 560.1V − 281.9 if V < 0.74 or P = 225.2V − surement is thereafter smoothed via a third-order polynomial fit. A
32.1 otherwise). discrete oscillogram is then formed by plotting the blood volume peaks
The blood volume waveform outputted by the PPG sensor is ampli- versus the corresponding pressure and smoothing the plot via a three-
fied and filtered via a band-pass filter with cutoff frequencies of 1.8 and point moving average. A final, continuous oscillogram is constructed by
4.3 Hz (analog signal conditioning) to differentiate the blood volume fitting the parametric function in Eq. 1 in Fig. 6 to the discrete oscillo-
waveform with respect to time while also attenuating high-frequency gram. In this equation, x and y are the abscissa and ordinate, respective-
noise. The applied pressure outputted by the force sensor is conditioned ly, of the oscillogram, and Ai and Bi are the parameters that define the
using circuitry provided with the sensor. The two measurements are oscillogram. This equation models the oscillogram as an asymmetric
then passed through an analog-to-digital converter (ADS1115, Adafruit) function, as justified elsewhere (29), via two half Gaussian functions.
As illustrated to the right of Eq. 1 in Fig. 6, the parameter A2 represents

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with 16-bit resolution and at a 40-Hz sampling rate. The digital signals
are finally transmitted to the smartphone via a development board with the starting value of the oscillogram; A1 and B1 represent the maximal
a processor (ATSAMD21G18, Arm) interfaced to a Bluetooth low- amplitude of the oscillogram and the applied pressure at which it is
energy module (nRF51822, Nordic Semiconductor). All components maximal, respectively; and B2 and B3 represent the width of the oscillo-
are powered with a rechargeable lithium-ion polymer battery (3.7 V, gram over the pressure range to the left and right of its maximum, re-
150 mA·hour), and switches are included to shut down the battery spectively. Note that the parameter A2 is needed, because the device asks
and sensors. the user to maintain a relatively constant pressure before beginning the
Software actuation (movie S1) such that the oscillogram is often flat initially.
We created an Android application to run on the smartphone. Figure 6 These five parameters are estimated via nonlinear least-squares fitting.
shows a flow chart of the application along with the important equa- The algorithm then computes BP from the final oscillogram or asks
tions for computing BP. The application includes a visual display to the user to try again. Empirical methods are used, similar to cuff-based
guide the finger actuation and an algorithm to compute and output devices that use fixed-ratio or similar methods to compute brachial BP
BP or ask the user to try again. The application uses various thresholds from an arm oscillogram (6, 7). In the fixed-ratio method, mean BP is
and BP computation formulas that were defined on the basis of the first obtained as the cuff pressure at which the oscillogram is maximal,
training data set. Formulas that optimized the agreement between the and systolic and diastolic BP are then determined as the cuff pressure at
smartphone-derived BP measurements and the reference arm cuff de- which the oscillogram is some fixed ratio of its maximal value. Similarly,
vice measurements were selected. Thresholds were selected qualitatively finger cuff devices based on the volume-clamp method convert the
by choosing what we considered to be reasonable values and then by measured finger BP to brachial BP via a population average transfer
confirming that these values allowed for what we considered to be a function and a regression equation (22). The brachial BP values are spe-
good balance between BP measurement accuracy and percentage of cifically computed from the finger oscillogram model parameters via
try again messages. the empirical linear regression formulas in Eqs. 2 to 4 in Fig. 6. We ar-
The visual display depicts separate graphs of the blood volume wave- rived at these formulas using stepwise regression (32), which deter-
form and applied pressure both plotted against time. Each sample of mined both the model parameters that are statistically significant
these measurements is displayed on its respective plot as it is being regressors (P < 0.05) of the reference cuff BP values and the associated
acquired. The applied pressure displayed specifically represents a 1-s coefficients in the regression model for computing BP. The diastolic BP
moving average. The applied pressure versus time plot also includes a formula is conceptually similar to the fixed-ratio method, and the con-
pair of blue lines, indicating a target rate range of 4.7 to 6.0 mmHg/s for stant term therein also accounts for brachial diastolic BP being system-
the pressure increase. The magnitude of the blood volume oscillations atically higher than finger diastolic BP (22, 33). The mean BP formula
is monitored in real time via a 1.33-s moving average of the SD of the includes both B1 and AA21 B2 (which is a measure of oscillogram width)
blood volume waveform. If this SD falls below 20% of its maximum and is therefore similar to an existing method designed to handle rel-
attained value, then the measurement automatically terminates because atively flat or wide oscillograms, in which the mean BP is determined
enough data have been obtained. Moreover, if three successive samples as the lowest external pressure at which the oscillogram is still close to
of the applied pressure fall outside of the two target blue lines, then the maximal (34). The constant term in the formula likewise accounts for
application will ask the user to try again. brachial mean BP being systematically higher than finger mean BP
The algorithm first constructs the oscillogram from the zero-mean (22, 33). The systolic BP formula is based on the 0.4/0.6 rule for com-
blood volume waveform and the applied pressure obtained during a puting brachial mean BP from brachial systolic and diastolic BP (30).
successful finger actuation. The measurements are analyzed over the Although stepwise regression yielded a different formula for systolic BP,
time interval for which the applied pressure ranges from 40 mmHg the degree of significance of the regressors was borderline (P ≅ 0.05).
to the termination pressure (TP). The average heart rate is determined Furthermore, the difference between brachial systolic BP and finger sys-
from the blood volume waveform based on its spectral peaks within the tolic BP is not only due to the resistive pressure drop but also due to
frequency range of 0.5 to 3 Hz. The peaks of each beat of the blood vol- arterial wave reflection and is therefore more complicated. Hence, the
ume waveform are then detected by leveraging the average heart rate simple formula here may generalize better. Finally, as shown to the left

Chandrasekhar et al., Sci. Transl. Med. 10, eaap8674 (2018) 7 March 2018 9 of 11
SCIENCE TRANSLATIONAL MEDICINE | RESEARCH ARTICLE

of Eqs. 2 to 4 in Fig. 6, if B2 or B3 is greater than 100 mmHg (the oscil- the number of BP values obtained and try again messages outputted
logram is excessively wide), A2 is less than 0 or greater than A1 (the os- by the device for each of the users, and determined the reason for each of
cillogram is negative or monotonically decreasing), the oscillogram the try agains via post hoc visual inspection of the data. To test accuracy,
amplitude at an applied pressure of 40 mmHg (y40) is greater than we averaged the cuff-less BP measurements of the smartphone-based
0.8A1, or the oscillation amplitude at the TP (yTP) is greater than device when multiple measurements were available for the user and
0.5A1 (the oscillogram has not been interrogated over a sufficiently wide averaged the pair of measurements from the arm cuff device. For the
pressure range), then the application will not output BP and instead will experienced users, we then added the rgh measurement to the systolic
ask the user to try again. Note that these empirical thresholds and and diastolic BP measurements from the arm cuff device. We did not
formulas are expected to change because more data are added to the assess the mean BP measurements from the smartphone-based device
training data set. because the reference device did not output this BP value, and use of the
0.4/0.6 rule for computing reference mean BP may bias the results.
Device testing: Formal human study Statistical analysis
We prospectively tested the smartphone-based device for usability and We used standard analyses to assess the systolic and diastolic BP mea-
accuracy against a standard automatic arm cuff device. surements of the smartphone-based device against the reference BP
Experimental subjects measurements from the arm cuff device. In particular, we assessed
We recruited 30 users who had not used the device before and 5 ex- the accuracy visually using correlation and Bland-Altman plots and
perienced users. These five users were part of the training data set sub- quantitatively using the correlation coefficient (r), bias error (m, mean

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ject cohort but performed an intervention to change their BP. The of the errors), and precision error (s, SD of the errors). For comparison,
inclusion criteria were: (i) from ages 21 to 60 years; (ii) right-handed we assessed the average brachial BP values obtained using the finger cuff
(because the device was designed for such users but could be easily device against the reference BP measurements from the standard cuff
extended for both right- and left-handed users); (iii) no cardiovascular device. The results of the devices were similar enough that statistical
disorders other than hypertension; and (iv) no problems with fine mo- comparisons were not necessary (Fig. 4).
tor control. The exclusion criterion for the accuracy testing was invalid
automatic cuff BP measurements defined as: (i) a poorly fit cuff on the
user’s arm or (ii) cuff BP measurements (mean via 0.4/0.6 rule) devi- SUPPLEMENTARY MATERIALS
ating by >10 mmHg (because BP was assumed to be stable throughout www.sciencetranslationalmedicine.org/cgi/content/full/10/431/eaap8674/DC1
Table S1. Anthropomorphic information, number of practice trials, and all BP measurements
the protocol). Only one user was excluded because of invalid cuff BP per subject.
measurements. Movie S1. Video demonstration of the smartphone-based BP monitoring device.
Experimental measurements and protocol
Figure 7 shows the BP measurement devices and protocol. The BP mea-
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Smartphone-based blood pressure monitoring via the oscillometric finger-pressing
method
Anand Chandrasekhar, Chang-Sei Kim, Mohammed Naji, Keerthana Natarajan, Jin-Oh Hahn and Ramakrishna
Mukkamala

Sci Transl Med 10, eaap8674.

DOI: 10.1126/scitranslmed.aap8674

Blood pressure at your fingertips

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Managing high blood pressure can reduce the risk of cardiovascular disease. Standard blood pressure
measurement devices use an inflatable arm cuff to vary the pressure applied to the brachial artery. For the
smartphone device developed by Chandrasekhar et al., the user provides external pressure on an artery in the
finger by pressing an optical sensor overlaying a force transducer on the back of a modified smartphone. The
phone runs an app to ensure that the user maintains sufficient finger contact while computing brachial artery blood
pressures from the finger-based measurements. The authors showed that blood pressure readings were similar
using their smartphone device, a standard arm cuff device, and a finger-cuff device in a group of participants. This
smartphone-based device could help make measuring blood pressure more accessible.

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