Journal of Clinical Monitoring and Computing

, Volume 18, Issue 5–6, pp 333–342 | Cite as

Pulse Transit Time by R-Wave-Gated Infrared Photoplethysmography: Review of the Literature and Personal Experience

  • Jochanan E. Naschitz
  • Stanislas Bezobchuk
  • Renata Mussafia-Priselac
  • Scott Sundick
  • Daniel Dreyfuss
  • Igal Khorshidi
  • Argyro Karidis
  • Hagit Manor
  • Mihael Nagar
  • Elisabeth Rubin Peck
  • Shannon Peck
  • Shimon Storch
  • Itzhak Rosner
  • Luis Gaitini


Objective. Pulse transit time (PTT) is the time it takes a pulse wave to travel between two arterial sites. A relatively short PTT is observed with high blood pressure (BP), aging, arteriosclerosis and diabetes mellitus. Most methods used for measuring the PTT are cumbersome and expensive. In contrast, the interval between the peak of the R-wave on the electrocardiogram and the onset of the corresponding pulse in the finger pad measured by photoplethysmography can be easily measured. We review herein the literature and impart the experience at our institution on clinical applications of R-wave-gated photoplethysmography (RWPP) as measurement of PTT. Methods. The MEDLINE data base on clinical applications of RWPP was reviewed. In addition, studies performed in the author’s institution are presented. Results. When used as a surrogate for beat-to-beat BP monitoring, RWPP did not meet the level of accuracy required for medical practice (two studies). RWPP produced accurate and reproducible signals when utilized as a surrogate for intra-thoracic pressure changes in obstructive sleep apnea, as well as BP arousals which accompany central sleep apnea (five studies). In estimation of arterial stiffness, RWPP was unsatisfactory (one study). In assessment of cardiovascular reactivity, abnormal values of RWPP were noted in autonomic failure (one study), while disease-specific reactivity patterns were identified utilizing a method involving RWPP (two studies). Conclusions. In clinical practice, sleep-apnea may be accurately monitored by RWPP. RWPP seems to reflect autonomic influences and may be particularly well-suited for the study of vascular reactivity. Thus, further descriptions of disease-specific cardiovascular reactivity patterns may be possible with techniques based on RWPP. Other clinical uses of RWPP are investigational.


infrared photoplethysmography blood pressure measurement arterial stiffness sleep apnea dysautonomia 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Smith RP, Argod J, Pepin JL, Levy PA. Pulse transit time: An appraisal of potential clinical applications. Thorax 1999; 54: 452–457.Google Scholar
  2. 2.
    Nitzan M, Khanokh B, Slovik Y. The difference in pulse transit time to the toe and finger measured by photoplethysmography. Physiol Meas 2002; 23: 85–93.Google Scholar
  3. 3.
    Asmar R, Benetos A, Topouchian J, Laurent P, Pannier B, Brisac AM, Target R, Levy BI. Assessment of arterial distensibility by automatic pulse wave velocity measurement. Validation and clinical application studies. Hypertension 1995; 26: 485–490.PubMedGoogle Scholar
  4. 4.
    Nagai Y, Fleg JL, Kemper MK, Rywik TM, Earley CJ, Metter EJ. Carotid arterial stiffness as a surrogate for aortic stiffness: Relationship between carotid artery pressure-strain elastic modulus and aortic pulse wave velocity. Ultrasound Med Biol 1999; 25: 181–188.CrossRefPubMedGoogle Scholar
  5. 5.
    O’Rourke MF. Isolated systolic hypertension, pulse pressure, and arterial stiffness as risk factors for cardiovascular disease. Curr Hypertens Rep 1999; 1: 204–211.PubMedGoogle Scholar
  6. 6.
    O’Rourke MF, Staessen JA, Vlachopoulos C, Duprez D, Plante GE. Clinical applications of arterial stiffness; definitions and reference values. Am J Hypertens 2002; 15: 426–444.CrossRefPubMedGoogle Scholar
  7. 7.
    O’Rourke MF, Hayward CS. Arterial stiffness, gender and heart rate. J Hypertens 2003; 21: 487–490.CrossRefPubMedGoogle Scholar
  8. 8.
    Allen J, Murray A. Prospective assessment of an artificial neural network for the detection of peripheral vascular disease from lower limb pulse waveforms. Physiol Meas 1995; 16: 29–38.CrossRefPubMedGoogle Scholar
  9. 9.
    van der Heijden-Spek JJ, Staessen JA, Fagard RH, Hoeks AP, Boudier HA, van Bortel LM. Effect of age on brachial artery wall properties differs from the aorta and is gender dependent: A population study. Hypertension 2000; 35: 637–642.PubMedGoogle Scholar
  10. 10.
    O’Rourke MF, Gallangher DE. Pulse wave analysis. J Hypertens 1996; 14: 147–157.PubMedGoogle Scholar
  11. 11.
    Lehmann ED, Hopkins KD, Rawesh A, Joseph RC, Kongola K, Coppack SW, Gosling RG. Relation between number of cardiovascular risk factors/events and noninvasive Doppler ultrasound assessments of aortic compliance. Hypertension 1998; 32: 565–569.PubMedGoogle Scholar
  12. 12.
    Lehmann ED, Hopkins KD, Gosling RG. Aortic compliance measurements using Doppler ultrasound: In vivo biochemical correlates. Ultrasound Med Biol 1993; 19: 683–710.CrossRefPubMedGoogle Scholar
  13. 13.
    Jago JR, Murray A. Repeatability of peripheral pulse measurements on ears, fingers and toes using photoelectric plethysmography. Clin Phys Physiol Meas 1988; 9: 319–330.CrossRefPubMedGoogle Scholar
  14. 14.
    Davies JI, Struthers AD. Pulse wave analysis and pulse wave velocity: A critical review of their strengths and weaknesses. J Hypertens 2003; 21: 463–472.CrossRefPubMedGoogle Scholar
  15. 15.
    Bernardi L, Saviolo R, Spodick DH. Noninvasive assessment of central circulatory pressures by analysis of ear densitographic changes during Valsalva maneuver. Am J Cardiol 1989; 64: 787–792.CrossRefPubMedGoogle Scholar
  16. 16.
    Challoner AVJ. Photoelectric plethysmography for estimating cutaneous blood flow. In: Rolfe P, ed. Non-invasive physiologic measurements. London: Academic Press, 1979: 125–151.Google Scholar
  17. 17.
    Argod J, Pepin JL, Smith RP, Levy P. Comparison of esophageal pressure with pulse transit time as a measure of respiratory effort for scoring obstructive nonapneic respiratory events. Am J Respir Crit Care Med 2000; 162: 87–93.PubMedGoogle Scholar
  18. 18.
    Bortolotto LA, Blacher J, Kondo T, Takazawa K, Safar ME. Assessment of vascular aging and atherosclerosis in hypertensive subjects: Second derivative of photoplethysmogram versus pulse wave velocity. Am J Hypertens 2000; 13: 165–171.CrossRefPubMedGoogle Scholar
  19. 19.
    Allen J, Murray A. Similarity in bilateral photoplethysmographic peripheral pulse wave characteristics at the ears, thumbs and toes. Physiol Meas 2000; 21: 369–377.CrossRefPubMedGoogle Scholar
  20. 20.
    Chen W, Tobahashi 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.PubMedGoogle Scholar
  21. 21.
    Pitson D, Chhina N, Knijn S, van Herwaaden M, Stradling J. Mechanisms of pulse transit time lengthening during inspiratory effort. J Ambul Monit 1995; 8: 101–105.Google Scholar
  22. 22.
    Naschitz JE, Sabo E, Naschitz S, Rozenbaum M, Rosner I, Musafia-Priselac R, Shaviv N, Ahdoot A, Ahdoot M, Gaitini L, Eldar S, Yeshurun D. Fractal analysis and recurrence quantification analysis of heart rate and pulse transit time for diagnosing chronic fatigue syndrome. Clin Autonom Res 2002; 12: 264–272.CrossRefGoogle Scholar
  23. 23.
    Naschitz JE, Rosner I, Shaviv N, Khorshidi I, Sundick S, Isseroff H, Fields M, Musafia Priselac R, Yeshurun D, Sabo E. Assessment of cardiovascular reactivity by fractal and recurrence quantification analysis of heart rate and pulse transit time. J Hum Hypertens 2003; 17: 111–118.CrossRefPubMedGoogle Scholar
  24. 24.
    Barschdorff D, Erig M. Continuous blood pressure monitoring during stress ECG. Biomed Tech (Berl) 1998; 43: 34–39.Google Scholar
  25. 25.
    Wippermann CF, Schranz D, Huth RG. Evaluation of the pulse wave arrival time as a marker for blood pressure changes in critically ill infants and children. J Clin Monit 1995; 11: 324–328.CrossRefPubMedGoogle Scholar
  26. 26.
    Training and certification of blood pressure observers. Hypertension 1983; 5: 610–614.Google Scholar
  27. 27.
    Weinman J, Ben-Yaakov S, Sapoznikov D. The application of photoplethysmography to the recording of Valsalva maneuver responses. Israel J Med Sci 1969; 5: 534–536.PubMedGoogle Scholar
  28. 28.
    Mathias CJ, Bannister R. Investigation of autonomic disorders. In: Mathias Ch J (ed.) Autonomic failure. A textbook of clinical disorders of the autonomic nervous system, 4th ed. Oxford, UK: Oxford Univeristy Press, 1999: 175–177.Google Scholar
  29. 29.
    Yano K, Kimora T, Sato Y, Nishiwaki K, Shimada Y. Delay time between the R-wave and maximum pulse wave upstroke reflects alterations in blood pressure. Anesthesiology 2002; 96: A491Google Scholar
  30. 30.
    Brock J, Pitson D, Strandling J. Use of pulse transit time as a measure of changes in inspiratory effort. J Ambul Monit 1993; 6: 295–302.Google Scholar
  31. 31.
    Pitson D, Chhina N, Knijn S, van Herwaaden M, Stradling J. Changes in pulse transit time and pulse rate as markers of arousal from sleep in normal subjects. Clin Sci (Lond) 1994; 87: 269–273.Google Scholar
  32. 32.
    Condos R, Norman RG, Krishnasamy I, Peduzzi N, Goldring RM, Rapoport DM. Flow limitation as a noninvasive assessment of residual upper-airway resistance during continuous positive airway pressure therapy of obstructive sleep apnea. Am J Respir Crit Care Med 1994; 150: 475–480.PubMedGoogle Scholar
  33. 33.
    Argod J, Pepin JL, Smith RP, Levy P. Comparison of esophageal pressure with pulse transit time as a measure of respiratory effort for scoring obstructive nonapneic respiratory events. Am J Respir Crit Care Med 2000; 162: 87–93.PubMedGoogle Scholar
  34. 34.
    Argod J, Pepin JL, Levy P. Differentiating obstructive and central sleep respiratory events through pulse transit time. Am J Respir Crit Care Med 1998; 158: 1778–1783.PubMedGoogle Scholar
  35. 35.
    Pitson DJ, Stradling JR. Autonomic markers of arousal during sleep in patients undergoing investigation for obstructive sleep apnea, their relationship to EEG arousals, respiratory events and subjective sleepiness. J Sleep Res. 1998; 7: 53–59.CrossRefPubMedGoogle Scholar
  36. 36.
    Glasser SP, Arnett DK, McVeigh GE, Finkelstein SM, Bank AJ, Morgan DJ, Cohn JN. Vascular compliance and cardiovascular disease: A risk factor or a marker? Am J Hypertens 1997; 10: 1175–1189.CrossRefPubMedGoogle Scholar
  37. 37.
    Mackenzie IS, Wilkinson IB, Cockcroft JR. Assessment of arterial stiffness in clinical practice. QJM 2002; 95: 67–74.CrossRefPubMedGoogle Scholar
  38. 38.
    Liao D, Arnett DK, Tyroler HA, Riley WA, Chambless LE, Szklo M, Heiss G. Arterial stiffness and the development of hypertension. The ARIC study. Hypertension 1999; 34: 201–206.PubMedGoogle Scholar
  39. 39.
    Resnick LM, Militianu D, Cunnings AJ, Pipe JG, Evelhoch JL, Soulen RL. Direct magnetic resonance determination of aortic distensibility is essential hypertension: Relation to age, abdominal visceral fat and in situ intracellular free magnesium. Hypertension 1997; 30: 645–649.Google Scholar
  40. 40.
    Wilkinson IB, Fuchs SA, Jansen IM, Spratt JC, Murray GD, Cockcroft JR, Webb DJ. Reproducibility of pulse wave velocity and augmentation index measured by pulse wave analysis. J Hypertens 1998; 16: 2079–2084.CrossRefPubMedGoogle Scholar
  41. 41.
    Hasegawa M, Nagao K, Kinoshita Y, Rodbard D, Asahina A. Increased pulse wave velocity and shortened pulse transmission time in hypertension and aging. Cardiology 1997; 88: 147–151.PubMedGoogle Scholar
  42. 42.
    Bernardi L, Radaelli A, Solda PL, Coats AJS, Reeder M. Autonomic control of skin microvessels: Assessment by power spectrum of photoplethysmography. Clin Sci 1996; 90: 345–355.PubMedGoogle Scholar
  43. 43.
    Ackselrod S, Gordon D, Madwed JB, Snidman NC, Shannon DC, Cohen RJ. Hemodynamic regulation: Investigation by spectral analysis. Am J Physiol 1985; 249: H867–H875.PubMedGoogle Scholar
  44. 44.
    Malliani A, Pagani M, Lombardi F, Cerruti S. Cardiovascular neural regulation explored in the frequency domain. Circulation 1991; 84: 482–492.PubMedGoogle Scholar
  45. 45.
    Nitzan M, Babchenko A, Khanokh B, Landau D. The variability of the photoplethysmographic signal – A potential method for the evaluation of the autonomic nervous system. Physiol Meas 1998; 19: 92–102.CrossRefGoogle Scholar
  46. 46.
    Pitson DJ, Sandell A, van den Hout R, Stradling JR. Use of pulse transit time as a measure of inspiratory effort in patients with obstructive sleep apnoea. Eur Respir J 1995; 8: 1669–1674.CrossRefPubMedGoogle Scholar
  47. 47.
    Wieling W, Karemaker JM. Measurement of heart rate and blood pressure to evaluate disturbances in neurocardiovascular control. In: Mathias ChJ (ed.) Autonomic failure. A textbook of clinical disorders of the autonomic nervous system, 4th ed. Oxford, UK: Oxford Univeristy Press, 1999: 198–210.Google Scholar
  48. 48.
    Naschitz JE, Sabo E, Naschitz S, Shaviv N, Rosner I, Rozenbaum M, Gaitini L, Ahdoot A, Ahdoot M, Priselac RM, Eldar S, Zukerman E, Yeshurun D. Hemodynamic instability in chronic fatigue syndrome: Indices and diagnostic significance. Semin Arthritis Rheum 2001; 31: 199–208.CrossRefPubMedGoogle Scholar
  49. 49.
    Naschitz JE, Sabo E, Naschitz S, Rosner I, Rozenbaum M, Fields M, Isseroff H, Musafia Priselac R, Gaitini L, Eldar S, Zukerman E, Yeshurun D. Hemodynamic instability score in chronic fatigue syndrome (CFS) and non-CFS chronic fatigue. Semin Arthritis Rheum 2002; 32: 141–148.CrossRefPubMedGoogle Scholar
  50. 50.
    Naschitz JE, Rosner I, Rozenbaum M, Fields M, Isseroff H, Babich JP, Zuckerman E, Elias N, Yeshurun D, Naschitz S, Sabo E. Disease-related phenotypes of cardiovascular reactivity as assessed by fractal and recurrence quantitative analysis of the heart rate and pulse transit time. Q J Med 2004; 97: 141–151.Google Scholar
  51. 51.
    Gribbin B, Streptoe A, Sleight P. Pulse wave velocity as a measure of blood pressure change. Psychophysiology 1976; 12: 86–90.Google Scholar
  52. 52.
    Geddes LA, Voelz MH, Babbs CF, Buirland JD, Tacker WA. Pulse transit time as an indicator of arterial blood pressure. Psychophysiology 1981; 18: 71–74.PubMedGoogle Scholar
  53. 53.
    Tanaka H, Sakamoto K, Kanai H. Indirect blood pressure measurement by the pulse wave velocity method. Med Electron Biol Eng 1984; 22: 13–18.Google Scholar
  54. 54.
    Lu W, Li H, Tao S, Zhang D, Jiang Z, Cui L, Tu J, Gou D. Research of the main elements influencing blood pressure measurement by pulse wave velocity. Front Med Biol Eng 1992; 4: 189–199.PubMedGoogle Scholar
  55. 55.
    Wipperman CF, Schranz D, Huth RG. Evaluation of pulse wave arrival time as a marker for blood pressure changes in critically ill infants and children. J Clin Monit 1995; 11: 324–328.CrossRefPubMedGoogle Scholar
  56. 56.
    Young CC, Mark JB, White W, DeBree A, Vender JS, Fleming A. Clinical evaluation of continuous blood pressure monitoring: Accuracy and tracking capabilities. J Clin Monit 1995; 11: 245–252.CrossRefPubMedGoogle Scholar
  57. 57.
    Dampney RA, Coleman MJ, Fontes MA, Hirooka Y, Horiuchi J, Li YW, Polson JW, Potts PD, Tagawa T. Central mechanisms underlying short- and long-term regulation of the cardiovascular system. Clin Exp Pharmacol Physiol. 2002; 29: 261–268.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, Inc. 2004

Authors and Affiliations

  • Jochanan E. Naschitz
    • 1
    • 5
  • Stanislas Bezobchuk
    • 1
  • Renata Mussafia-Priselac
    • 1
  • Scott Sundick
    • 1
  • Daniel Dreyfuss
    • 1
  • Igal Khorshidi
    • 1
  • Argyro Karidis
    • 1
  • Hagit Manor
    • 1
  • Mihael Nagar
    • 1
  • Elisabeth Rubin Peck
    • 1
  • Shannon Peck
    • 1
  • Shimon Storch
    • 2
  • Itzhak Rosner
    • 3
  • Luis Gaitini
    • 4
  1. 1.Departments of Internal Medicine ATechnion-Israel Institute of TechnologyHaifaIsrael
  2. 2.NephrologyTechnion-Israel Institute of TechnologyHaifaIsrael
  3. 3.RheumatologyTechnion-Israel Institute of TechnologyHaifaIsrael
  4. 4.Anesthesiology, Bnai-Zion Medical Center and Bruce Rappaport Faculty of MedicineTechnion-Israel Institute of TechnologyHaifaIsrael
  5. 5.Department of Internal Medicine ABnai Zion Medical CenterHaifaIsrael

Personalised recommendations