Cuffless Blood Pressure Estimation Research Articles

Advancing cuffless blood pressure estimation: A PPG-based multi-task learning model for enhanced feature extraction and fusion

Cuffless continuous blood pressure (BP) monitoring is essential for personalized health management. Although existing cuffless BP estimation applies advanced machine learning techniques and integrates PPG signals, it is deficient in feature extraction and fusion. In addition, it is inefficient to train the model separately for different tasks. In this study, an advanced multi-domain and local–global feature parallel multi-task learning network (MDLG-MTLNet) is introduced. The MDLG-MTLNet was designed with three key aspects: first, temporal and multi-scale spatial features were extracted from PPG signals and their derivatives via a multi-scale spatial and temporal feature block; interaction of features from different domains was facilitated by the introduction of a local–global attention module that captured and efficiently fused local–global information; and lastly, intrinsic correlation between systolic (SBP) and diastolic blood pressure (DBP) was taken into account via a multi-task learning network to improve the overall performance of the model. On the MIMIC-II dataset, the MAEs of MDLG-MTLNet for DBP, SBP, and MBP were 2.64 mmHg, 1.57 mmHg, and 2.02 mmHg, respectively. These errors were superior to those of the existing methods, meeting the AAMI criteria, and earning an A grade according to the BHS protocol. The experimental results confirm the effectiveness of our proposed model in feature extraction and fusion.

CiGNN: A Causality-Informed and Graph Neural Network Based Framework for Cuffless Continuous Blood Pressure Estimation.

Causalityholds profound potentials to dissipate confusion and improve accuracy in cuffless continuous blood pressure (BP) estimation, an area often neglected in current research. In this study, we propose a two-stage framework, CiGNN, that seamlessly integrates causality and graph neural network (GNN) for cuffless continuous BP estimation. The first stage concentrates on the generation of a causal graph between BP and wearable features from the the perspective of causal inference, so as to identify features that are causally related to BP variations. This stage is pivotal for the identification of novel causal features from the causal graph beyond pulse transit time (PTT). We found these causal features empower better tracking in BP changes compared to PTT. For the second stage, a spatio-temporal GNN (STGNN) is utilized to learn from the causal graph obtained from the first stage. The STGNN can exploit both the spatial information within the causal graph and temporal information from beat-by-beat cardiac signals for refined cuffless continuous BP estimation. We evaluated the proposed method with three datasets that include 305 subjects (102 hypertensive patients) with age ranging from 20-90 and BP at different levels, with the continuous Finapres BP as references. The mean absolute difference (MAD) for estimated systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 3.77 mmHg and 2.52 mmHg, respectively, which outperformed comparison methods. In all cases including subjects with different age groups, while doing various maneuvers that induces BP changes at different levels and with or without hypertension, the proposed CiGNN method demonstrates superior performance for cuffless continuous BP estimation. These findings suggest that the proposed CiGNN is a promising approach in elucidating the causal mechanisms of cuffless BP estimation and can substantially enhance the precision of BP measurement.

Schrödinger spectrum and slim CNN architecture-based signal quality estimation for Photoplethysmogram signals

Photoplethysmography (PPG) signal comprises physiological information related to cardiorespiratory health. However, these signals are often contaminated by motion artifacts, resulting in low-quality noise-enriched signals. Therefore, it is crucial to ensure high-quality signals to extract accurate cardiorespiratory information. Although several rule-based and Machine-Learning (ML) - based approaches exist for PPG signal quality estimation but their effectiveness is questionable during evaluation in diverse datasets. This study proposes a lightweight, slim CNN architecture that utilizes a novel Quantum Pattern Recognition (QPR) technique for signal quality assessment. The proposed algorithm is initially validated on the University of Queensland database (clinical) and a noisy PPG database (non-clinical) collected from the ‘Welltory app’. A total of 28366, 5 s signal segments are preprocessed and transformed into image files of 20 × 500 pixels. The image files and heart rate obtained from the PPG signals are treated as input to the 2D slim CNN architecture. The developed model classifies the PPG signal as ‘good’ or ‘bad’ with an accuracy of 98.5%, 99.2% sensitivity, 97.5% specificity, and 99% F1-score. The classified database is further used for cuffless Blood Pressure estimation, and estimation error is reduced ≥ 1 mmHg w.r.t. reference BP signals. Finally, the proposed scheme is validated in STM32 series board for a resource-constrained wearable implementation. The computational load of the algorithm is reduced by network pruning and quantization for edge-device implementation, and it achieves an accuracy of 94.3%. This extensive analysis concludes that a slim architecture, along with a novel spatio–temporal pattern recognition technique, improves the system’s performance.

Validation of deep learning models for cuffless blood pressure estimation on a large benchmarking dataset

Objective: This study aims to evaluate the effectiveness of deep learning techniques in estimating cuffless blood pressure (BP) across a diverse patient population in intensive care units (ICUs). Methods: A comprehensive ICU benchmarking dataset encompassing 2,154 patients with a wide demographic range (18-97 years old) and varied cardiovascular status was employed to validate several deep learning models in predicting continuous BP waveforms. Three methods were developed to enhance the model's generalizability to this heterogeneous dataset. Ten-fold subject-independent cross-validation was performed and the model performance was assessed through mean absolute error (MAE), Pearson’s correlation coefficient (PCC), and compared with significance analysis. Results: The UTransBPNet_Demo_In model, which incorporated demographic and physiological signals as inputs, achieved a PCC of 0.89 and a MAE of 10.38 mmHg in predicting arterial BP waveforms, demonstrating the highest tracking capability among all models. Notably, the performance of UTransBPNet_Demo_In remained robust across variations in demographic and cardiovascular status. Conclusion: The UTransBPNet_Demo_In model demonstrates robust predictive capabilities across a broad spectrum of demographics and cardiovascular conditions. Although the performance still needs further improvement, this study offers a benchmark in the field of cuffless BP monitoring in critical care settings for future studies.

Cuffless blood pressure estimation from photoplethysmography using deep convolutional neural network and transfer learning

Blood pressure (BP) monitoring is an essential indicator for diseases of the cardiovascular system. Early detection of abnormalities in BP helps to significantly reduce the risk of diseases such as chronic heart failure, stroke and hypertension. In this study, we propose a new framework for systolic, diastolic and mean arterial blood pressure (SBP, DBP and MBP) estimation using PPG signals and its derivatives. The proposed framework includes the extraction of deep features by pre-trained CNN models based on transfer learning using images of signal waveforms. The most distinctive features are obtained by using the RFE feature selection algorithm on the extracted deep features. The selected deep features are exposed to a range of well-known machine and deep learning regression methods. The proposed BP estimation models have been evaluated with statistical metrics, visual analytical tools and international gold standards such as AAMI and BHS. Experimental results show that the first derivative of PPG, the VPG input image, the deep features obtained with DenseNet121 and the bi-directional gated recurrent unit (Bi-GRU) algorithm provide the best BP estimation performance. The results reveal that the SBP, DBP and MBP estimation models are grade-A according to the BHS protocol and meet the AAMI standard. The presented framework has been compared with well-established studies using the MIMIC II dataset, and the comparative analysis confirms that the proposed method outperforms existing techniques. The deep learning model for BP estimation offers a highly accurate, fast and practical system, especially in the monitoring of patients at risk of hypertension.

Variational Autoencoders for Biomedical Signal Morphology Clustering and Noise Detection.

Accurate estimation of physiological biomarkers using raw waveform data from non-invasive wearable devices requires extensive data preprocessing. An automatic noise detection method in time-series data would offer significant utility for various domains. As data labeling is onerous, having a minimally supervised abnormality detection method for input data, as well as an estimation of the severity of the signal corruptness, is essential. We propose a model-free, time-series biomedical waveform noise detection framework using a Variational Autoencoder coupled with Gaussian Mixture Models, which can detect a range of waveform abnormalities without annotation, providing a confidence metric for each segment. Our technique operates on biomedical signals that exhibit periodicity of heart activities. This framework can be applied to any machine learning or deep learning model as an initial signal validator component. Moreover, the confidence score generated by the proposed framework can be incorporated into different models' optimization to construct confidence-aware modeling. We conduct experiments using dynamic time warping (DTW) distance of segments to validated cardiac cycle morphology. The result confirms that our approach removes noisy cardiac cycles and the remaining signals, classified as clean, exhibit a 59.92% reduction in the standard deviation of DTW distances. Using a dataset of bio-impedance data of 97885 cardiac cycles, we further demonstrate a significant improvement in the downstream task of cuffless blood pressure estimation, with an average reduction of 2.67 mmHg root mean square error (RMSE) of Diastolic Blood pressure and 2.13 mmHg RMSE of systolic blood pressure, with increases of average Pearson correlation of 0.28 and 0.08, with a statistically significant improvement of signal-to-noise ratio respectively in the presence of different synthetic noise sources. This enables burden-free validation of wearable sensor data for downstream biomedical applications.

BrainZ-BP: A Noninvasive Cuff-Less Blood Pressure Estimation Approach Leveraging Brain Bio-Impedance and Electrocardiogram

BrainZ-BP: A Noninvasive Cuff-Less Blood Pressure Estimation Approach Leveraging Brain Bio-Impedance and Electrocardiogram

Photoplethysmography-based cuffless blood pressure estimation: an image encoding and fusion approach

Objective. Photoplethysmography (PPG) is a promising wearable technology that detects volumetric changes in microcirculation using a light source and a sensor on the skin’s surface. PPG has been shown to be useful for non-invasive blood pressure (BP) measurement. Deep learning-based BP measurements are now gaining popularity. However, almost all methods focus on 1D PPG. We aimed to design an end-to-end approach for estimating BP using image encodings from a 2D perspective. Approach. In this paper, we present a BP estimation approach based on an image encoding and fusion (BP-IEF) technique. We convert the PPG into five image encodings and use them as input. The proposed BP-IEF consists of two parts: an encoder and a decoder. In addition, three kinds of well-known neural networks are taken as the fundamental architecture of the encoder. The decoder is a hybrid architecture that consists of convolutional and fully connected layers, which are used to fuse features from the encoder. Main results. The performance of the proposed BP-IEF is evaluated on the UCI database in both non-mixed and mixed manners. On the non-mixed dataset, the root mean square error and mean absolute error for systolic BP (SBP) are 13.031 mmHg and 9.187 mmHg respectively, while for diastolic BP (DBP) they are 5.049 mmHg and 3.810 mmHg. On the mixed dataset, the corresponding values for SBP are 4.623 mmHg and 3.058 mmHg, while for DBP the values are 2.350 mmHg and 1.608 mmHg. In addition, both SBP and DBP estimation on the mixed dataset achieved grade A compared to the British Hypertension Society standard. The DBP estimation on the non-mixed dataset also achieved grade A. Significance. The results indicate that the proposed approach has the potential to improve on the current mobile healthcare for cuffless BP measurement.

Schrödinger spectrum based continuous cuff-less blood pressure estimation using clinically relevant features from PPG signal and its second derivative

The presented study estimates cuff-less blood pressure (BP) from photoplethysmography (PPG) signals using multiple machine-learning (ML) models and the semi-classical signal analysis (SCSA) technique. The study proposes a novel signal reconstruction algorithm, which optimizes the semi-classical constant of the SCSA approach and eliminates the trade-off between complexity and accuracy during signal reconstruction. It predicts BP values using regression algorithms by processing reconstructed PPG signals’ spectral features, extracting clinically relevant PPG and its second derivative’s (SDPPG) morphological features. The developed method was assessed using a virtual in-silico dataset with more than 4000 subjects and the Multi-Parameter Intelligent Monitoring in Intensive Care Units (MIMIC-II) dataset. Results showed that the method attained a mean absolute error (MAE) of 5.37 and 2.96 mmHg for systolic and diastolic BP, respectively, using the CatBoost algorithm. This approach met the Association for the Advancement of Medical Instrumentation’s standard and achieved Grade A for all BP categories in the British Hypertension Society protocol. The proposed framework performs well even when applied to a combined clinically relevant database originating from MIMIC-III and the Queensland dataset. The proposed method’s performance is further evaluated in a non-clinical setting with noisy and deformed PPG signals to validate the efficacy of the SCSA method. The noise stress tests further showed that the algorithm maintained its key feature detection, signal reconstruction capability, and estimation accuracy up to a 10 dB SNR ratio. The proposed cuff-less BP estimation technique has the potential to perform well in mobile healthcare devices due to its straightforward implementation approach.

Effects of Pulse Transit Time and Pulse Arrival Time on Cuff-less Blood Pressure Estimation: A Comparison Study with Multiple Experimental Interventions.

Pulse transit time (PTT) has shown a correlation with blood pressure (BP), and it is considered as a potential marker for cuff-less BP estimation. However, pulse arrival time (PAT) including pre-ejection period (PEP) has been utilized more widely because of its convenience to acquisition and calculation. In spite of this, whether PAT can surrogate PTT has been a controversial topic for many years. In this study, we designed an experiment on 55 subjects with multiple interventions, those may cause the changes in BP and PEP. We analyzed the linear and nonlinear correlations between BP and PTT/PAT, and also assessed the performances of PTT-based and PAT-based models on tracking the BP variation. Five typical BP estimation models were used for comparison. We found that PEP could change rapidly in response to the interventions related with physical stress. Although PTT had a better linear correlation with BP, most of the PAT-based models showed more accuracy than PTT-based models in all of the interventions, especially for the calibrated models. It is suggested that PAT has the potential to predict BP, and the inclusion of PEP in the measurement of PAT is necessary.

Continual Learning for Cuffless Blood Pressure Measurement using PPG and ECG Signals.

Although numerous studies have been conducted on cuffless blood pressure (BP) estimation using machine learning methods, most of the data-driven models are static, with model parameters fixed after training is complete. However, BP is dynamic and the performance would degrade for a static model when the to-be predicted BP distribution deviates from the training BP distribution. In this paper, we propose a continual learning (CL) framework in which deep learning models are developed to learn dynamically and continuously for arterial BP (ABP) estimation with photoplethysmography (PPG) and electrocardiogram (ECG) waveforms. The effectiveness of the CL model is validated on UCI Repository and MIMIC-III database with a total of 132 individual samples, and compared with conventional training method. It was found that the CL model improved the ABP estimation accuracy in terms of mean absolute error (MAE) by 17.47% on average compared with conventional training model. Furthermore, the improvement increased with the variability of ABP. These results demonstrate that CL model has potential to estimate dynamic ABP, which has been challenging with conventional training.

Boosting Algorithms based Cuff-less Blood Pressure Estimation from Clinically Relevant ECG and PPG Morphological Features.

Blood Pressure (BP) is often coined as a critical physiological marker for cardiovascular health. Multiple studies have explored either Photoplethysmogram (PPG) or ECG-PPG derived features for continuous BP estimation using machine learning (ML); deep learning (DL) techniques. Majority of those derived features often lack a stringent biological explanation and are not significantly correlated with BP. In this paper, we identified several clinically relevant (bio-inspired) ECG and PPG features; and exploited them to estimate Systolic (SBP), and Diastolic Blood Pressure (DBP) values using CatBoost, and AdaBoost algorithms. The estimation performance was then compared against popular ML algorithms. SBP and DBP achieved a Pearson's correlation coefficient of 0.90 and 0.83 between estimated and target BP values. The estimated mean absolute error (MAE) values are 3.81 and 2.22 mmHg with a Standard Deviation of 6.24 and 3.51 mmHg, respectively, for SBP and DBP using CatBoost. The results surpassed the Advancement of Medical Instrumentation (AAMI) standards. For the British Hypertension Society (BHS) protocol, the results achieved for all the BP categories resided in Grade A. Further investigation reveals that bio-inspired features along with tuned ML models can produce comparable results w.r.t parameter-intensive DL networks. ln(HR × mNPV), HR, BMI index, ageing index, and PPG-K point were identified as the top five key features for estimating BP. The group-based analysis further concludes that a trade-off lies between the number of features and MAE. Increasing the no. of features beyond a certain threshold saturates the reduction in MAE.

Investigation of Data Leakage in Deep-Learning-Based Blood Pressure Estimation Using Photoplethysmogram/Electrocardiogram

Cuff-less blood pressure (BP) estimation methods using a deep learning model from photoplethysmogram (PPG) or electrocardiogram (ECG) have been actively studied in recent years. However, we found that most previous studies incur data leakage, where segments or records measured from the same subject appear in both the training and test datasets. Furthermore, many previous studies are suspected to have misinterpreted a record in the public dataset used for their evaluations as a subject. To investigate data leakage in BP estimation methods, this paper first organizes previous studies in terms of data leakage. We then quantitatively evaluate the effect of data leakage caused by the segment-level and the record-level train-test split using the public dataset, Cuff-Less Blood Pressure Estimation Data Set. Our experimental results showed that the segment-level split and record-level split erroneously improved the estimation accuracy of mean blood pressure from the (quasi-)subject-level split by the Pearson’s correlation coefficient of 0.56 and 0.40 when using PPG, and 0.82 and 0.69 when using ECG, respectively. These results confirmed that the train-test split used in many previous studies, including the one that described its evaluation as causing no data leakage, causes a high level of data leakage, and that a record in the Cuff-Less Blood Pressure Estimation Data Set, often misinterpreted as a subject in previous studies, is not a subject and that a high level of data leakage occurs when the record is considered as a subject.

A mixed attention-gated U-Net for continuous cuffless blood pressure estimation

A mixed attention-gated U-Net for continuous cuffless blood pressure estimation

Physics-informed neural networks for modeling physiological time series for cuffless blood pressure estimation

The bold vision of AI-driven pervasive physiological monitoring, through the proliferation of off-the-shelf wearables that began a decade ago, has created immense opportunities to extract actionable information for precision medicine. These AI algorithms model input-output relationships of a system that, in many cases, exhibits complex nature and personalization requirements. A particular example is cuffless blood pressure estimation using wearable bioimpedance. However, these algorithms need training over significant amount of ground truth data. In the context of biomedical applications, collecting ground truth data, particularly at the personalized level is challenging, burdensome, and in some cases infeasible. Our objective is to establish physics-informed neural network (PINN) models for physiological time series data that would use minimal ground truth information to extract complex cardiovascular information. We achieve this by building Taylor’s approximation for gradually changing known cardiovascular relationships between input and output (e.g., sensor measurements to blood pressure) and incorporating this approximation into our proposed neural network training. The effectiveness of the framework is demonstrated through a case study: continuous cuffless BP estimation from time series bioimpedance data. We show that by using PINNs over the state-of-the-art time series models tested on the same datasets, we retain high correlations (systolic: 0.90, diastolic: 0.89) and low error (systolic: 1.3 ± 7.6 mmHg, diastolic: 0.6 ± 6.4 mmHg) while reducing the amount of ground truth training data on average by a factor of 15. This could be helpful in developing future AI algorithms to help interpret pervasive physiologic data using minimal amount of training data.

Quantitative analysis of pulse arrival time and PPG morphological features based cuffless blood pressure estimation: a comparative study between diabetic and non-diabetic groups.

Pulse arrival time (PAT) and PPG morphological features have attracted much interest in cuffless blood pressure (BP) estimation, but their effects are not clearly understood when vascular characteristics are affected by diseases such as diabetes. This work quantitatively analyzes the effect of diabetic disease on the PAT and PPG morphological features-based BP estimation. We selected 112 diabetic patients and 308 non-diabetic subjects from VitalDB, and extracted 16 features including PAT, PPG morphological features, and heart rate. BP estimation performance was statistically compared between groups using linear regression models with several feature sets, and the relative importance of each feature in the optimal feature set was extracted. As a result, the standard deviation of the error and mean absolute error of PAT-based BP estimation were significantly higher in the diabetic group than in the non-diabetic group (p < 0.01). A feature set containing PAT and PPG morphological features achieved the best performance in both groups. However, the relative importance of each feature for BP estimation differed notably between groups. The results indicate that different features are important depending on the vascular characteristics, which could help to construct different models to accommodate specific diseases.

Continuous cuffless blood pressure monitoring using photoplethysmography-based PPG2BP-net for high intrasubject blood pressure variations

Continuous, comfortable, convenient (C3), and accurate blood pressure (BP) measurement and monitoring are needed for early diagnosis of various cardiovascular diseases. To supplement the limited C3 BP measurement of existing cuff-based BP technologies, though they may achieve reliable accuracy, cuffless BP measurement technologies, such as pulse transit/arrival time, pulse wave analysis, and image processing, have been studied to obtain C3 BP measurement. One of the recent cuffless BP measurement technologies, innovative machine-learning and artificial intelligence-based technologies that can estimate BP by extracting BP-related features from photoplethysmography (PPG)-based waveforms have attracted interdisciplinary attention of the medical and computer scientists owing to their handiness and effectiveness for both C3 and accurate, i.e., C3A, BP measurement. However, C3A BP measurement remains still unattainable because the accuracy of the existing PPG-based BP methods was not sufficiently justified for subject-independent and highly varying BP, which is a typical case in practice. To circumvent this issue, a novel convolutional neural network(CNN)- and calibration-based model (PPG2BP-Net) was designed by using a comparative paired one-dimensional CNN structure to estimate highly varying intrasubject BP. To this end, approximately 70%, 20%, and 10% of 4185 cleaned, independent subjects from 25,779 surgical cases were used for training, validating, and testing the proposed PPG2BP-Net, respectively and exclusively (i.e., subject-independent modelling). For quantifying the intrasubject BP variation from an initial calibration BP, a novel ‘standard deviation of subject-calibration centring (SDS)’ metric is proposed wherein high SDS represents high intrasubject BP variation from the calibration BP and vice versa. PPG2BP-Net achieved accurately estimated systolic and diastolic BP values despite high intrasubject variability. In 629-subject data acquired after 20 minutes following the A-line (arterial line) insertion, low error mean and standard deviation of 0.209pm 7.509 and 0.150pm 4.549;textrm{mmHg} for highly varying A-line systolic and diastolic BP values, respectively, where their SDSs are 15.375 and 8.745. This study moves one step forward in developing the C3A cuffless BP estimation devices that enable the push and agile pull services.

Comparison of seven shallow and deep regressors in continuous blood pressure and heart rate estimation using single-channel photoplethysmograms under three evaluation cases

Our objective is to compare seven blood pressure (BP) and heart rate (HR) estimation models based on shallow and deep regressors using single-channel photoplethysmograms (PPGs) under three evaluation cases. Non-invasive, cuffless, continuous, and simultaneous estimation of systolic BP, diastolic BP, and HR using only PPGs is valuable for routinely monitoring the health status using simple device configuration. However, the performances of regressors cannot be directly compared based on the metrics presented in their respective papers because they use different datasets and evaluation procedures. Therefore, we used a common dataset (containing 1811 patients) and prepared three evaluation cases in which the training and testing data included, partly included, and did not include data from the same subjects. Shallow models using hand-crafted features performed reasonably well, and when the training data contained data similar to the testing data, deep models using raw signals as input achieved accurate BP and HR estimation. The spectral–temporal residual network showed the highest performance, with modified PP-Net as the runner-up; this study revealed that they are strong candidates for non-invasive, cuffless, continuous, and simultaneous BP and HR estimation models using single-channel PPGs in clinical and daily-use scenarios. Furthermore, results showed that the estimation performances rely on the level of inclusion of same subjects’ data in the training and testing data. To address the discrepancy between pre-measured data domain and new user’s data domain, we will investigate effective transfer learning techniques in the future work. The training and testing datasets used in this study are made public (https://drive.google.com/drive/folders/14nSeg0V-metCIs3LHPBH9tolxiyCN8eA?usp=share_link).

A PPG-Based Calibration-Free Cuffless Blood Pressure Estimation Method Using Cardiovascular Dynamics.

Traditional cuff-based sphygmomanometers for measuring blood pressure can be uncomfortable and particularly unsuitable to use during sleep. A proposed alternative method uses dynamic changes in the pulse waveform over short intervals and replaces calibration with information from photoplethysmogram (PPG) morphology to provide a calibration-free approach using a single sensor. Results from 30 patients show a high correlation of 73.64% for systolic blood pressure (SBP) and 77.72% for diastolic blood pressure (DBP) between blood pressure estimated with the PPG morphology features and the calibration method. This suggests that the PPG morphology features could replace the calibration stage for a calibration-free method with similar accuracy. Applying the proposed methodology on 200 patients and testing on 25 new patients resulted in a mean error (ME) of -0.31 mmHg, a standard deviation of error (SDE) of 4.89 mmHg, a mean absolute error (MAE) of 3.32 mmHg for DBP and an ME of -4.02 mmHg, an SDE of 10.40 mmHg, and an MAE of 7.41 mmHg for SBP. These results support the potential for using a PPG signal for calibration-free cuffless blood pressure estimation and improving accuracy by adding information from cardiovascular dynamics to different methods in the cuffless blood pressure monitoring field.

Causal inference based cuffless blood pressure estimation: A pilot study

Enabled by wearable sensing, e.g., photoplethysmography (PPG) and electrocardiography (ECG), and machine learning techniques, study on cuffless blood pressure (BP) measurement with data-driven methods has become popular in recent years. However, causality has been overlooked in most of current studies. In this study, we aim to examine the feasibility of causal inference for cuffless BP estimation. We first attempt to detect wearable features that are causally related, rather than correlated, to BP changes by identifying causal graphs of interested variables with fast causal inference (FCI) algorithm. With identified causal features, we then employ time-lagged link to integrate the mechanism of causal inference into the BP estimated model. The proposed method was validated on 62 subjects with their continuous ECG, PPG and BP signals being collected. We found new causal features that can better track BP changes than pulse transit time (PTT). Further, the developed causal-based estimation model achieved an estimation error of mean absolute difference (MAD) being 5.10 mmHg and 2.85 mmHg for SBP and DBP, respectively, which outperformed traditional model without consideration of causality. To the best of our knowledge, this work is the first to study the causal inference for cuffless BP estimation, which can shed light on the mechanism, method and application of cuffless BP measurement.