![Editorial comment 2341
The finger volume pulse and assessment of arterial
properties
Alberto Avolio
Journal of Hypertension 2002, 20:2341–2343
Graduate School of Biomedical Engineering, University of New South Wales,
Sydney, Australia.
Correspondence and requests for reprints to A. Avolio, Graduate School of
Biomedical Engineering, University of New South Wales, Sydney 2052,
Australia.
Fax: +61 296 632108; e-mail: a.avolio@unsw.edu.au
See original paper on page 2415
Introduction not only to peripheral flow, but also to arterial elastic
The non-invasive assessment of cardiovascular function properties and haemodynamic parameters that relate
by means of the peripheral arterial pulse has gained both pressure and flow. [7–10]. The assumption is that
substantial interest in recent years due to the integra- factors affecting pressure/flow relations and wave propa-
tion of sensor technology and the ubiquitous applica- gation will modify the peripheral volume pulse. The
tion of microprocessors. In its most basic use, the study by Hashimoto et al. [1] extends previous work by
peripheral pulse provides a signal that establishes the other investigators [10,11]. While these previous studies
presence of a beating heart and quantifies the cardiac assessed changes in specific features of the second
rhythm and its variability with time. However, when derivative of finger volume pulse, Hashimoto et al. [1]
transduction methods are employed that relate signal compare changes in these features with those in
output to system biophysical properties, measures of surrogate measures of arterial stiffness measured by
vascular haemodynamics can be derived from the pulse pulse wave velocity in a group of hypertensive subjects
waveform features. In this issue of the journal, Hashi- in whom the blood pressure was normalized by anti-
moto et al. [1] use parameters derived from the photo- hypertenive treatment over a period of 15 years.
plethysmographic signal obtained in the finger to
establish relations between the peripheral pulse wave- Photoplethysmography and the finger volume
form features and stiffness parameters of central large pulse
arteries. The photoplethysmogram is measured by a device
comprising an infrared light source (typically a photo-
The measurement of alteration of intensity of absorbed diode emitting light at a wavelength of around 900 nm)
light due to changes in haemoglobin content with each and a photodetector (phototransistor). The precise
heart beat has been applied since the late 1930s to origin of the photoplethysmographic (PPG) signal has
quantify changes in skin blood flow [2,3]. Because the not been firmly established [12], but the light intensity
peripheral volume blood flow pulse is essentially due to is modulated in a complex fashion by the increase in
a propagating pressure pulse, the time course of the haemoglobin content and expansion of the vascular and
signal indicating flow changes bears a relationship to tissue volume between the light source and the detec-
pressure changes. While a photoplethysmographic sig- tor, such that there is a reduction of the signal with
nal can be obtained at any location on the skin surface each heart beat [12,13].
[3,4], the finger is a convenient site at which to apply a
sensor and record a continuous volume signal. This Although the PPG signal is related in time and morph-
signal is used in pulse oxymetry devices for monitoring ology to the arterial pressure pulse, the wave contour is
blood oxygen content [5] and to the quantify level of not the same. Millasseau et al. [14] have quantified the
anaesthesia [6]. However, a substantial amount of work relationship between the PPG signal in the index finger
has emanated from Japan where the concept of analys- and the pressure pulse obtained non-invasively by the
ing the finger volume signal waveshape has been volume clamping technique in the middle finger of the
applied extensively, relating pulse waveform features same hand. They found that the modulus of the
0263-6352 & 2002 Lippincott Williams & Wilkins](https://image.slidesharecdn.com/sdptg3-100604162558-phpapp02/85/Sdptg-3-1-320.jpg)
![2342 Journal of Hypertension 2002, Vol 20 No 12
transfer function between the pressure signal and the with age when applied to large population groups
PPG volume pulse showed a significant peak at [10,11].
approximately 6 Hz, with almost double the amplitude
relative to that at heart rate frequency. This implies Pulse wave velocity and SDPTG
that the volume pulse is more damped than the The methodology employed by Hashimoto et al. [1] to
pressure pulse and there is relative loss of frequency measure pulse wave velocity (PWV) utilizes an addi-
content in the region 1–6 Hz. These factors become tional signal from the phonocardiogram. The transit
relevant when attempting to relate volume signals to time (t) is obtained from the pulse signals measured
pressure-related parameters. simultaneously at the carotid and femoral arteries and
the distance (D) is obtained as the superficial distance
The vasculature in the fingers contains an abundance between the second intercostal space and at the
of alpha adrenergic receptors, so the peripheral blood sternum and the femoral artery location. D is then
flow is markedly influenced by sympathetic activity as corrected by a factor of 1.3 to account for the aortic
well as temperature variations [3,15,16]. These effects curvature and t is increased by a factor tc obtained from
can produce significant errors, such as to accentuate the time difference between the second heart sound
local effects when relating volume pulse waveform and at the incisura of the carotid pulse. Although this
parameters to central large artery properties. These, technique differs somewhat from the recommended
together with problems related to cuff occlusions, are guidelines developed recently [21], the PWV values
some of the potential sources of error relevant to the calculated in this way show the expected changes with
application of the PPG signal in the Penaz volume age.
clamping technique [17], which is used for calibrated
and continuous non-invasive measurement of arterial While PWV measured by Hashimoto et al. [1] is
pressure (e.g. Finapres device [18]). essentially a property of the distensibility of the aortic
wall and depends passively on arterial pressure, the
parameters derived from the peripheral pulse contain
Use of the second derivative of the PPG components that depend on both central and peripheral
signal effects. Furthermore, aortic PWV does not depend on
Because the PPG signal is qualitatively related to the the time course of ventricular ejection (as long as
pressure pulse, and the shape of the pressure pulse has pressure remains unchanged), whereas the shape of the
been shown to be associated with arterial properties peripheral pulse depends on both the time course of
such as generalized arterial stiffness that occurs with ventricular ejection and central and peripheral wave
age or effects of vasoactive agents [19], features of the transmission and reflection phenomena [22]. An in-
PPG signal, such as the height of the inflection point crease in acceleration of the early ejection phase would
relative to pulse height, have been used to quantify affect the b/a ratio of the SDPTG but would not be
haemodynamic parameters such as wave reflection [20]. detected as a change in PWV. Hence, when relating
However, because of the smooth appearance of the parameters derived from the peripheral pulse to aortic
PPG signal due to damping, other features, such as stiffness measured by PWV, the inherent assumption is
early and late systolic inflections, cannot be detected that the aortic flow wave remains unchanged. Although
readily. Thus, the second derivative signal (SDPTG) Hashimoto et al. [1] do not address this issue explicitly,
was proposed [10] as a means to accentuate and locate but mention it as a possible limitation to the study, the
inflection points and a specific nomenclature has been assumption would seem to apply to the population
adopted, such that five sequential waves are designated studied because it was essentially homogenous in terms
a, b, c, d and e. The a, b, c and d waves occur in systole of age (61.4 Æ 10.5 years) and antihypertensive treat-
and e in diastole. The height is expressed in relation to ment (87% being on calcium channel blockers).
the height of the a wave, and extensive use has been
made of the parameters to quantify changes in arterial Overall, the study found a significant relationship be-
parameters [1,9,10,11]. The ratios b/a and d/a have been tween parameters of SDPTG and PWV, although the
shown to have a strong relationship with age and d/a correlation coefficients were relatively low (–0.164 for
with systolic augmentation index derived from the b/a and 0.239 for d/a). The explanation is that PWV and
central aortic pressure [10]. Because there is a known SDPTG are associated with different mechanisms and
association of age and pulse wave velocity, the study by reflect different information with respect to central and
Hashimoto et al. [1] examines the possible relationship peripheral arterial properties. This is an important
between absolute values of d/a and b/a with pulse wave observation. However, while there may be some merit
velocity. An age index (AGI) has also been determined in uncovering specific haemodynamic mechanisms, it is
as (b – c – d – e)/a. [1,10]. While there is no specific important to acknowledge the substantial effects of the
reason given for defining AGI in this way, it was found measurement technique itself and the potential sources
that this parameter has a strong correlation (r ¼ 0.75) of errors that could be present. Although there is](https://image.slidesharecdn.com/sdptg3-100604162558-phpapp02/85/Sdptg-3-2-320.jpg)
![The finger volume pulse and assessment of arterial properties Avolio 2343
substantial individual variability in the SDPTG para- 11 Bortolotto LA, Blacher J, Kondo T, Takazawa K, Safar ME. Assessment of
meters, such as PWV, it can be a useful tool for vascular aging and atherosclerosis in hypertensive subjects: second
derivative of photoplethysmogram vs. pulse wave velocity. Am J Hyper-
studying large populations or groups with specific tens 2000; 13:165–171.
cardiovascular diseases. This was evident in the differ- 12 Jespersen LT, Pedersen OL. The quantitative aspect of photoplethysmo-
graphy revised. Heart Vessels 1986; 2:186–190.
ence in results in subjects with uncontrolled hyper- 13 Babchenko A, Davidson E, Ginosar Y, Kurz V, Faib I, Adler D, Nitzan M.
tension [1,11]. A recent study has also demonstrated Photoplethysmographic measurement of changes in total and pulsatile
the potential use of this technique to study changes in tissue blood volume, following sympathetic blockade. Physiol Meas
2001; 22:389–396.
arterial distensibility during development in a large 14 Millasseau SC, Guigui FG, Kelly RP, Prasad K, Cockcroft JR, Ritter JM,
(n ¼ 1495) population of children and adolescents aged Chowienczyk PJ. Noninvasive assessment of the digital volume pulse.
Comparison with the peripheral pressure pulse. Hypertension 2000;
9–17 years [23]. 36:952–956.
15 Hertzman AB, Orth LW. The vasomotor components in the vascular
Effect of heart rate reactions in the finger to cold. Am J Physiol 1942; 136:669–679.
16 Heyman F, Ahlberg NE. Effect of rapid distension of large arteries and
One of the findings of the study by Hashimoto et al. [1] veins on the vascular tone of the fingers Acta Med Scand 1968;
was a dependence of PWV and b/a and d/a ratios on 183:337–340.
17 ˜´
Penaz J. Photoelectric measurement of blood pressure, volume and flow
heart rate. If this is independent of blood pressure, the
in the finger. Digest of the 10th International Conference on Medical and
implication is that heart rate has an intrinsic effect on Biological Engineering. Dresden; 1973. p. 104.
large artery stiffness. This observation has to be taken 18 Imholz BP, Wieling W, van Montfrans GA, Wesseling KH. Fifteen years
experience with finger arterial pressure monitoring: assessment of the
with caution, especially if PWV is measured in the technology. Cardiovasc Res 1998; 38:605–616.
aortic trunk, where the passive pressure effects on wall 19 O’Rourke MF, Kelly RP, Avolio AP. The arterial pulse. London: Lea and
stiffness are much greater than active effects due to Febiger; 1992.
20 Chowienczyk PJ, Kelly RP, MacCallum H, Millasseau SC, Andersson TL,
sympathetic influences on smooth muscle tone. Gosling RG, et al. Photoplethysmographic assessment of pulse wave
Although a number of studies have shown a heart rate reflection: blunted response to endothelium-dependent beta2-adrenergic
vasodilation in type II diabetes mellitus. J Am Coll Cardiol 1999;
dependence on large artery stiffness [24], the possibility 34:2007–2014.
of measurement errors in accurate calculation of transit 21 Van Bortel LM, Duprez D, Starmans-Kool MJ, Safar ME, Giannattasio C,
times or pulse waveform features cannot be discounted, Cockcroft J, et al. Clinical applications of arterial stiffness, Task Force III:
recommendations for user procedures. Am J Hypertens 2002; 15:
especially in studies showing the dependence of heart 445–452.
rate and arterial stiffness with cardiac pacing [25]. A 22 Nichols WW, O’Rourke MF. McDonald’s blood flow in arteries. London:
recent study by Green et al. [26] has shown no effect of Arnold; 1998.
23 Miyai N, Miyashita K, Arita M, Morioka I, Kamiya K, Takeda S. Noninvasive
cardiac pacing on forearm vascular response when assessment of arterial distensibility in adolescents using the second
measured in terms of changes in diameter for the same derivative of photoplethysmogram waveform. Eur J Appl Physiol 2001;
86:119–124.
pulse pressure. 24 Cunha RS, Pannier B, Benetos A, Siche J-P, London GM, Mallion JM,
Safar ME Association between high heart rate and high arterial rigidity in
References normotensive and hypertensive subjects J Hypertens 1997; 15:
1423–1430.
1 Hashimoto J, Chonal K, Aokei Y, Nishimura T, Ohkubo T, Hozawa A, et al.
Pulse wave velocity and the second derivative of the finger photoplethys- 25 Lantelme P, Mestre C, Lievre M, Gressard A, Milon H. Heart rate: an
important confounder of pulse wave velocity assessment. Hypertension
mogram in treated hypertensive patients: their relationship and associat-
ing factors. J Hypertens 2002, 20:2415–2422. 2002; 39:1083–1087.
26 Green D, Cheetham C, Henderson C, Weerasooriya R, O’Driscoll G.
2 Herzman AB, Spealman C. Observations of the finger volume pulse
Effect of cardiac pacing on forearm vascular responses and nitric oxide
recorded photo-electrically. Am J Physiol 1937; 119:334–335.
3 Hertzman AB. The blood supply of various skin areas as estimated by the function. Am J Physiol Heart Circ Physiol 2002; 283:H1354–H1360.
photoelectric plethysmograph. Am J Physiol 1938; 124:328–340.
4 Loukogeorgakis S, Dawson R, Phillips N, Martyn CN, Greenwald S.
Validation of a device to measure arterial pulse wave velocity. Physiol
Measurement 2002; 23:581–596.
5 Mendelson Y, Ochs BD. Noninvasive pulse oximetry utilizing skin reflec-
tance photoplethysmography. IEEE Trans Biomed Eng 1988; 35:
798–805.
6 Larsen PD, Harty M, Thiruchelvam M, Galletly DC. Spectral analysis of
AC and DC components of the pulse photoplethysmograph at rest and
during induction of anaesthesia. Int J Clin Monit Comput 1997; 14:
89–95.
7 Ando J, Kawarada A, Shibata M, Yamakoshi K, Kamiya A. Pressure–
volume relationships of finger arteries in healthy subjects and patients
with coronary atherosclerosis measured non-invasively by photoelectric
plethysmography. Jpn Circ J 1991; 55:567–575.
8 Kawarada A, Shimazu H, Yamakoshi K, Kamiya A. Noninvasive automatic
measurement of arterial elasticity in human fingers and rabbit forelegs
using photoelectric plethysmography. Med Biol Eng Comput 1986;
24:591–596.
9 Takada H, Washino K, Harrel JS, Iwata H. Acceleration plethysmography
to evaluate aging effect in cardiovascular system. Using new criteria of
four wave patterns. Med Prog Technol 1997; 21:205–210.
10 Takazawa K, Tanaka N, Fujita M, Matsuoka O, Saiki T, Aikawa M, et al.
Assessment of vasoactive agents and vascular aging by the second
derivative of photoplethysmogram waveform. Hypertension 1998;
32:365–370.](https://image.slidesharecdn.com/sdptg3-100604162558-phpapp02/85/Sdptg-3-3-320.jpg)
Sdptg 3
- 1. Editorial comment 2341 The finger volume pulse and assessment of arterial properties Alberto Avolio Journal of Hypertension 2002, 20:2341–2343 Graduate School of Biomedical Engineering, University of New South Wales, Sydney, Australia. Correspondence and requests for reprints to A. Avolio, Graduate School of Biomedical Engineering, University of New South Wales, Sydney 2052, Australia. Fax: +61 296 632108; e-mail: a.avolio@unsw.edu.au See original paper on page 2415 Introduction not only to peripheral flow, but also to arterial elastic The non-invasive assessment of cardiovascular function properties and haemodynamic parameters that relate by means of the peripheral arterial pulse has gained both pressure and flow. [7–10]. The assumption is that substantial interest in recent years due to the integra- factors affecting pressure/flow relations and wave propa- tion of sensor technology and the ubiquitous applica- gation will modify the peripheral volume pulse. The tion of microprocessors. In its most basic use, the study by Hashimoto et al. [1] extends previous work by peripheral pulse provides a signal that establishes the other investigators [10,11]. While these previous studies presence of a beating heart and quantifies the cardiac assessed changes in specific features of the second rhythm and its variability with time. However, when derivative of finger volume pulse, Hashimoto et al. [1] transduction methods are employed that relate signal compare changes in these features with those in output to system biophysical properties, measures of surrogate measures of arterial stiffness measured by vascular haemodynamics can be derived from the pulse pulse wave velocity in a group of hypertensive subjects waveform features. In this issue of the journal, Hashi- in whom the blood pressure was normalized by anti- moto et al. [1] use parameters derived from the photo- hypertenive treatment over a period of 15 years. plethysmographic signal obtained in the finger to establish relations between the peripheral pulse wave- Photoplethysmography and the finger volume form features and stiffness parameters of central large pulse arteries. The photoplethysmogram is measured by a device comprising an infrared light source (typically a photo- The measurement of alteration of intensity of absorbed diode emitting light at a wavelength of around 900 nm) light due to changes in haemoglobin content with each and a photodetector (phototransistor). The precise heart beat has been applied since the late 1930s to origin of the photoplethysmographic (PPG) signal has quantify changes in skin blood flow [2,3]. Because the not been firmly established [12], but the light intensity peripheral volume blood flow pulse is essentially due to is modulated in a complex fashion by the increase in a propagating pressure pulse, the time course of the haemoglobin content and expansion of the vascular and signal indicating flow changes bears a relationship to tissue volume between the light source and the detec- pressure changes. While a photoplethysmographic sig- tor, such that there is a reduction of the signal with nal can be obtained at any location on the skin surface each heart beat [12,13]. [3,4], the finger is a convenient site at which to apply a sensor and record a continuous volume signal. This Although the PPG signal is related in time and morph- signal is used in pulse oxymetry devices for monitoring ology to the arterial pressure pulse, the wave contour is blood oxygen content [5] and to the quantify level of not the same. Millasseau et al. [14] have quantified the anaesthesia [6]. However, a substantial amount of work relationship between the PPG signal in the index finger has emanated from Japan where the concept of analys- and the pressure pulse obtained non-invasively by the ing the finger volume signal waveshape has been volume clamping technique in the middle finger of the applied extensively, relating pulse waveform features same hand. They found that the modulus of the 0263-6352 & 2002 Lippincott Williams & Wilkins
- 2. 2342 Journal of Hypertension 2002, Vol 20 No 12 transfer function between the pressure signal and the with age when applied to large population groups PPG volume pulse showed a significant peak at [10,11]. approximately 6 Hz, with almost double the amplitude relative to that at heart rate frequency. This implies Pulse wave velocity and SDPTG that the volume pulse is more damped than the The methodology employed by Hashimoto et al. [1] to pressure pulse and there is relative loss of frequency measure pulse wave velocity (PWV) utilizes an addi- content in the region 1–6 Hz. These factors become tional signal from the phonocardiogram. The transit relevant when attempting to relate volume signals to time (t) is obtained from the pulse signals measured pressure-related parameters. simultaneously at the carotid and femoral arteries and the distance (D) is obtained as the superficial distance The vasculature in the fingers contains an abundance between the second intercostal space and at the of alpha adrenergic receptors, so the peripheral blood sternum and the femoral artery location. D is then flow is markedly influenced by sympathetic activity as corrected by a factor of 1.3 to account for the aortic well as temperature variations [3,15,16]. These effects curvature and t is increased by a factor tc obtained from can produce significant errors, such as to accentuate the time difference between the second heart sound local effects when relating volume pulse waveform and at the incisura of the carotid pulse. Although this parameters to central large artery properties. These, technique differs somewhat from the recommended together with problems related to cuff occlusions, are guidelines developed recently [21], the PWV values some of the potential sources of error relevant to the calculated in this way show the expected changes with application of the PPG signal in the Penaz volume age. clamping technique [17], which is used for calibrated and continuous non-invasive measurement of arterial While PWV measured by Hashimoto et al. [1] is pressure (e.g. Finapres device [18]). essentially a property of the distensibility of the aortic wall and depends passively on arterial pressure, the parameters derived from the peripheral pulse contain Use of the second derivative of the PPG components that depend on both central and peripheral signal effects. Furthermore, aortic PWV does not depend on Because the PPG signal is qualitatively related to the the time course of ventricular ejection (as long as pressure pulse, and the shape of the pressure pulse has pressure remains unchanged), whereas the shape of the been shown to be associated with arterial properties peripheral pulse depends on both the time course of such as generalized arterial stiffness that occurs with ventricular ejection and central and peripheral wave age or effects of vasoactive agents [19], features of the transmission and reflection phenomena [22]. An in- PPG signal, such as the height of the inflection point crease in acceleration of the early ejection phase would relative to pulse height, have been used to quantify affect the b/a ratio of the SDPTG but would not be haemodynamic parameters such as wave reflection [20]. detected as a change in PWV. Hence, when relating However, because of the smooth appearance of the parameters derived from the peripheral pulse to aortic PPG signal due to damping, other features, such as stiffness measured by PWV, the inherent assumption is early and late systolic inflections, cannot be detected that the aortic flow wave remains unchanged. Although readily. Thus, the second derivative signal (SDPTG) Hashimoto et al. [1] do not address this issue explicitly, was proposed [10] as a means to accentuate and locate but mention it as a possible limitation to the study, the inflection points and a specific nomenclature has been assumption would seem to apply to the population adopted, such that five sequential waves are designated studied because it was essentially homogenous in terms a, b, c, d and e. The a, b, c and d waves occur in systole of age (61.4 Æ 10.5 years) and antihypertensive treat- and e in diastole. The height is expressed in relation to ment (87% being on calcium channel blockers). the height of the a wave, and extensive use has been made of the parameters to quantify changes in arterial Overall, the study found a significant relationship be- parameters [1,9,10,11]. The ratios b/a and d/a have been tween parameters of SDPTG and PWV, although the shown to have a strong relationship with age and d/a correlation coefficients were relatively low (–0.164 for with systolic augmentation index derived from the b/a and 0.239 for d/a). The explanation is that PWV and central aortic pressure [10]. Because there is a known SDPTG are associated with different mechanisms and association of age and pulse wave velocity, the study by reflect different information with respect to central and Hashimoto et al. [1] examines the possible relationship peripheral arterial properties. This is an important between absolute values of d/a and b/a with pulse wave observation. However, while there may be some merit velocity. An age index (AGI) has also been determined in uncovering specific haemodynamic mechanisms, it is as (b – c – d – e)/a. [1,10]. While there is no specific important to acknowledge the substantial effects of the reason given for defining AGI in this way, it was found measurement technique itself and the potential sources that this parameter has a strong correlation (r ¼ 0.75) of errors that could be present. Although there is
- 3. The finger volume pulse and assessment of arterial properties Avolio 2343 substantial individual variability in the SDPTG para- 11 Bortolotto LA, Blacher J, Kondo T, Takazawa K, Safar ME. Assessment of meters, such as PWV, it can be a useful tool for vascular aging and atherosclerosis in hypertensive subjects: second derivative of photoplethysmogram vs. pulse wave velocity. Am J Hyper- studying large populations or groups with specific tens 2000; 13:165–171. cardiovascular diseases. This was evident in the differ- 12 Jespersen LT, Pedersen OL. The quantitative aspect of photoplethysmo- graphy revised. Heart Vessels 1986; 2:186–190. ence in results in subjects with uncontrolled hyper- 13 Babchenko A, Davidson E, Ginosar Y, Kurz V, Faib I, Adler D, Nitzan M. tension [1,11]. A recent study has also demonstrated Photoplethysmographic measurement of changes in total and pulsatile the potential use of this technique to study changes in tissue blood volume, following sympathetic blockade. Physiol Meas 2001; 22:389–396. arterial distensibility during development in a large 14 Millasseau SC, Guigui FG, Kelly RP, Prasad K, Cockcroft JR, Ritter JM, (n ¼ 1495) population of children and adolescents aged Chowienczyk PJ. Noninvasive assessment of the digital volume pulse. Comparison with the peripheral pressure pulse. Hypertension 2000; 9–17 years [23]. 36:952–956. 15 Hertzman AB, Orth LW. The vasomotor components in the vascular Effect of heart rate reactions in the finger to cold. Am J Physiol 1942; 136:669–679. 16 Heyman F, Ahlberg NE. Effect of rapid distension of large arteries and One of the findings of the study by Hashimoto et al. [1] veins on the vascular tone of the fingers Acta Med Scand 1968; was a dependence of PWV and b/a and d/a ratios on 183:337–340. 17 ˜´ Penaz J. Photoelectric measurement of blood pressure, volume and flow heart rate. If this is independent of blood pressure, the in the finger. Digest of the 10th International Conference on Medical and implication is that heart rate has an intrinsic effect on Biological Engineering. Dresden; 1973. p. 104. large artery stiffness. This observation has to be taken 18 Imholz BP, Wieling W, van Montfrans GA, Wesseling KH. Fifteen years experience with finger arterial pressure monitoring: assessment of the with caution, especially if PWV is measured in the technology. Cardiovasc Res 1998; 38:605–616. aortic trunk, where the passive pressure effects on wall 19 O’Rourke MF, Kelly RP, Avolio AP. The arterial pulse. London: Lea and stiffness are much greater than active effects due to Febiger; 1992. 20 Chowienczyk PJ, Kelly RP, MacCallum H, Millasseau SC, Andersson TL, sympathetic influences on smooth muscle tone. Gosling RG, et al. Photoplethysmographic assessment of pulse wave Although a number of studies have shown a heart rate reflection: blunted response to endothelium-dependent beta2-adrenergic vasodilation in type II diabetes mellitus. J Am Coll Cardiol 1999; dependence on large artery stiffness [24], the possibility 34:2007–2014. of measurement errors in accurate calculation of transit 21 Van Bortel LM, Duprez D, Starmans-Kool MJ, Safar ME, Giannattasio C, times or pulse waveform features cannot be discounted, Cockcroft J, et al. Clinical applications of arterial stiffness, Task Force III: recommendations for user procedures. Am J Hypertens 2002; 15: especially in studies showing the dependence of heart 445–452. rate and arterial stiffness with cardiac pacing [25]. A 22 Nichols WW, O’Rourke MF. McDonald’s blood flow in arteries. London: recent study by Green et al. [26] has shown no effect of Arnold; 1998. 23 Miyai N, Miyashita K, Arita M, Morioka I, Kamiya K, Takeda S. Noninvasive cardiac pacing on forearm vascular response when assessment of arterial distensibility in adolescents using the second measured in terms of changes in diameter for the same derivative of photoplethysmogram waveform. Eur J Appl Physiol 2001; 86:119–124. pulse pressure. 24 Cunha RS, Pannier B, Benetos A, Siche J-P, London GM, Mallion JM, Safar ME Association between high heart rate and high arterial rigidity in References normotensive and hypertensive subjects J Hypertens 1997; 15: 1423–1430. 1 Hashimoto J, Chonal K, Aokei Y, Nishimura T, Ohkubo T, Hozawa A, et al. Pulse wave velocity and the second derivative of the finger photoplethys- 25 Lantelme P, Mestre C, Lievre M, Gressard A, Milon H. Heart rate: an important confounder of pulse wave velocity assessment. Hypertension mogram in treated hypertensive patients: their relationship and associat- ing factors. J Hypertens 2002, 20:2415–2422. 2002; 39:1083–1087. 26 Green D, Cheetham C, Henderson C, Weerasooriya R, O’Driscoll G. 2 Herzman AB, Spealman C. Observations of the finger volume pulse Effect of cardiac pacing on forearm vascular responses and nitric oxide recorded photo-electrically. Am J Physiol 1937; 119:334–335. 3 Hertzman AB. The blood supply of various skin areas as estimated by the function. Am J Physiol Heart Circ Physiol 2002; 283:H1354–H1360. photoelectric plethysmograph. Am J Physiol 1938; 124:328–340. 4 Loukogeorgakis S, Dawson R, Phillips N, Martyn CN, Greenwald S. Validation of a device to measure arterial pulse wave velocity. Physiol Measurement 2002; 23:581–596. 5 Mendelson Y, Ochs BD. Noninvasive pulse oximetry utilizing skin reflec- tance photoplethysmography. IEEE Trans Biomed Eng 1988; 35: 798–805. 6 Larsen PD, Harty M, Thiruchelvam M, Galletly DC. Spectral analysis of AC and DC components of the pulse photoplethysmograph at rest and during induction of anaesthesia. Int J Clin Monit Comput 1997; 14: 89–95. 7 Ando J, Kawarada A, Shibata M, Yamakoshi K, Kamiya A. Pressure– volume relationships of finger arteries in healthy subjects and patients with coronary atherosclerosis measured non-invasively by photoelectric plethysmography. Jpn Circ J 1991; 55:567–575. 8 Kawarada A, Shimazu H, Yamakoshi K, Kamiya A. Noninvasive automatic measurement of arterial elasticity in human fingers and rabbit forelegs using photoelectric plethysmography. Med Biol Eng Comput 1986; 24:591–596. 9 Takada H, Washino K, Harrel JS, Iwata H. Acceleration plethysmography to evaluate aging effect in cardiovascular system. Using new criteria of four wave patterns. Med Prog Technol 1997; 21:205–210. 10 Takazawa K, Tanaka N, Fujita M, Matsuoka O, Saiki T, Aikawa M, et al. Assessment of vasoactive agents and vascular aging by the second derivative of photoplethysmogram waveform. Hypertension 1998; 32:365–370.