Beyond Atrial Fibrillation: Emerging Clinical Applications of Photoplethysmography in Consumer Wearables
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Introduction: Photoplethysmography (PPG) is an optical sensing technology embedded in many current consumer smartwatches and smart rings. Long used for heart-rate monitoring and pulse oximetry, PPG has more recently become the foundation for population-scale screening for atrial fibrillation. The clinical applications of PPG now extend well beyond rhythm monitoring.
Method: A narrative literature review of English-language publications indexed in PubMed, Europe PMC, IEEE Xplore, and Google Scholar between January 2020 and May 2026 was conducted, using combinations of the search term photoplethysmography with application-specific search terms. Earlier foundational publications were included selectively where necessary.
Discussion: Current evidence most strongly supports consumer-wearable PPG for resting heart-rate estimation and for atrial-fibrillation notification pathways with adjudicated electrocardiographic confirmation. SpO2 trending is conditionally supported in healthy, normoxaemic adults but is insufficient for clinical decision-making during desaturation, motion, low perfusion, or in populations under-represented in validation datasets. Cuffless blood-pressure estimation, heart-rate variability, sleep staging, and obstructive sleep apnoea screening show device-, context-, and reference-standard-dependent reliability. Non-invasive blood-glucose monitoring through smartwatches or smart rings should not be used for diabetes management and is the subject of an explicit FDA safety communication.
Conclusion: Consumer-wearable PPG is a multifunctional clinical sensing platform whose evidence maturity differs sharply by application. Responsible deployment requires awareness of signal quality, motion artefact, skin-tone bias, regulatory authorisation status, and local validation, particularly in the Indonesian primary-care context.
- References
-
1. Allen J. Photoplethysmography and its application in clinical physiological measurement. Physiol Meas. 2007;28(3):R1-39.
2. Charlton PH, Allen J, Bailón R, Baker S, Behar JA, Chen F, et al. The 2023 wearable photoplethysmography roadmap. Physiol Meas. 2023;44(11):111001.
3. Castaneda D, Esparza A, Ghamari M, Soltanpur C, Nazeran H. A review on wearable photoplethysmography sensors and their potential future applications in health care. Int J Biosens Bioelectron. 2018;4(4):195-202.
4. Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T, et al. Large-scale assessment of a smartwatch to identify atrial fibrillation. N Engl J Med. 2019;381(20):1909-17.
5. Lubitz SA, Faranesh AZ, Selvaggi C, Atlas SJ, McManus DD, Singer DE, et al. Detection of atrial fibrillation in a large population using wearable devices: the Fitbit Heart Study. Circulation. 2022;146(19):1415-24.
6. Rizas KD, Freyer L, Sappler N, von Stülpnagel L, Spielbichler P, Krasniqi A, et al. Smartphone-based screening for atrial fibrillation: a pragmatic randomized clinical trial. Nat Med. 2022;28(9):1823-30.
7. Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5.
8. Elgendi M. Optimal signal quality index for photoplethysmogram signals. Bioengineering (Basel). 2016;3(4):21.
9. IEEE Standards Association. IEEE standard for wearable, cuffless blood pressure measuring devices: amendment 1 (IEEE Std 1708a-2019). New York: IEEE; 2019.
10. Park J, Seok HS, Kim SS, Shin H. Photoplethysmogram analysis and applications: an integrative review. Front Physiol. 2022;12:808451.
11. Almarshad MA, Islam MS, Al-Ahmadi S, BaHammam AS. Diagnostic features and potential applications of PPG signal in healthcare: a systematic review. Healthcare (Basel). 2022;10(3):547.
12. Mukkamala R, Stergiou GS, Avolio AP. Cuffless blood pressure measurement. Annu Rev Biomed Eng. 2022;24:203-30.
13. Vybornova A, Polychronopoulou E, Wurzner-Ghajarzadeh A, Fallet S, Sola J, Wuerzner G. Blood pressure from the optical Aktiia Bracelet: a 1-month validation study using an extended ISO 81060-2 protocol adapted for a cuffless wrist device. Blood Press Monit. 2021;26(4):305-11.
14. Falter M, Scherrenberg M, Driesen K, Pieters Z, Kaihara T, Xu L, et al. Smartwatch-based blood pressure measurement demonstrates insufficient accuracy. Front Cardiovasc Med. 2022;9:958212.
15. Wang L, Xian H, Guo J, Li W, Wang J, Chen Q, et al. A novel blood pressure monitoring technique by smart HUAWEI WATCH: a validation study according to the ANSI/AAMI/ISO 81060-2:2018 guidelines. Front Cardiovasc Med. 2022;9:923655.
16. Islam SMS, Chow CK, Daryabeygikhotbehsara R, Subedi N, Rawstorn J, Tegegne T, et al. Wearable cuffless blood pressure monitoring devices: a systematic review and meta-analysis. Eur Heart J Digit Health. 2022;3(2):323-37.
17. Stergiou GS, Avolio AP, Palatini P, Kyriakoulis KG, Schutte AE, Mieke S, et al. European Society of Hypertension recommendations for the validation of cuffless blood pressure measuring devices. J Hypertens. 2023;41(12):2074-87.
18. Mukkamala R, Yavarimanesh M, Natarajan K, Hahn JO, Kyriakoulis KG, Avolio AP, et al. Evaluation of the accuracy of cuffless blood pressure measurement devices: challenges and proposals. Hypertension. 2021;78(5):1161-7.
19. Stergiou GS, Mukkamala R, Avolio A, Kyriakoulis KG, Mieke S, Murray A, et al. Cuffless blood pressure measuring devices: review and statement by the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability. J Hypertens. 2022;40(8):1449-60.
20. US Food and Drug Administration. Do not use unauthorized devices for measuring blood pressure: FDA safety communication [Internet]. Silver Spring (MD): FDA; 2025 Sep 16 [cited 2026 May 22]. Available from: https://www.fda.gov/medical-devices/safety-communications/do-not-use-unauthorized-devices-measuring-blood-pressure-fda-safety-communication
21. US Food and Drug Administration. Cuffless non-invasive blood pressure measuring devices: clinical performance testing and evaluation. Draft guidance for industry and Food and Drug Administration staff [Internet]. Silver Spring (MD): FDA; 2026 Jan [cited 2026 May 22]. Docket FDA-2025-D-0851. Available from: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/cuffless-non-invasive-blood-pressure-measuring-devices-clinical-performance-testing-and-evaluation
22. US Food and Drug Administration. 510(k) premarket notification: G0 Blood Pressure Monitoring System, K250415 [Internet]. Silver Spring (MD): FDA; 2025 Jul 2 [cited 2026 May 22]. Available from: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K250415
23. US Food and Drug Administration. Warning letter: WHOOP, Inc., CMS #709755 [Internet]. Silver Spring (MD): FDA; 2025 Jul 14 [cited 2026 May 22]. Available from: https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/whoop-inc-709755-07142025
24. Spaccarotella C, Polimeni A, Mancuso C, Pelaia G, Esposito G, Indolfi C. Assessment of non-invasive measurements of oxygen saturation and heart rate with an Apple smartwatch: comparison with a standard pulse oximeter. J Clin Med. 2022;11(6):1467.
25. Pipek LZ, Nascimento RFV, Acencio MMP, Teixeira LR. Comparison of SpO2 and heart rate values on Apple Watch and conventional commercial oximeters devices in patients with lung disease. Sci Rep. 2021;11(1):18901.
26. Jiang Y, Spies C, Magin J, Bhosai SJ, Snyder L, Dunn J. Investigating the accuracy of blood oxygen saturation measurements in common consumer smartwatches. PLOS Digit Health. 2023;2(7):e0000296.
27. Lauterbach CJ, Romano PA, Greisler LA, Brindle RA, Ford KR, Kuennen MR. Accuracy and reliability of commercial wrist-worn pulse oximeter during normobaric hypoxia exposure under resting conditions. Res Q Exerc Sport. 2021;92(3):549-58.
28. US Food and Drug Administration. Pulse oximeter basics [Internet]. Silver Spring (MD): FDA; [updated 2025 Mar 26; cited 2026 Sep 27]. Available from: https://www.fda.gov/consumers/consumer-updates/pulse-oximeter-basics
29. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477-8.
30. Valbuena VSM, Seelye S, Sjoding MW, Valley TS, Dickson RP, Gay SE, et al. Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013-19: multicenter, retrospective cohort study. BMJ. 2022;378:e069775.
31. Fawzy A, Wu TD, Wang K, Robinson ML, Farha J, Bradke A, et al. Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients with COVID-19. JAMA Intern Med. 2022;182(7):730-8.
32. US Food and Drug Administration. Pulse oximeters for medical purposes: non-clinical and clinical performance testing, labeling, and premarket submission recommendations. Draft guidance for industry and Food and Drug Administration staff [Internet]. Silver Spring (MD): FDA; 2025 Jan [cited 2026 Sep 27]. Docket FDA-2023-N-4976. Available from: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/pulse-oximeters-medical-purposes-non-clinical-and-clinical-performance-testing-labeling-and
33. Colvonen PJ, DeYoung PN, Bosompra NA, Owens RL. Limiting racial disparities and bias for wearable devices in health science research. Sleep. 2020;43(10):zsaa159.
34. Koerber D, Khan S, Shamsheri T, Kirubarajan A, Mehta S. Accuracy of heart rate measurement with wrist-worn wearable devices in various skin tones: a systematic review. J Racial Ethn Health Disparities. 2023;10(6):2676-84.
35. Bent B, Goldstein BA, Kibbe WA, Dunn JP. Investigating sources of inaccuracy in wearable optical heart rate sensors. NPJ Digit Med. 2020;3:18.
36. Hinde K, White G, Armstrong N. Wearable devices suitable for monitoring twenty four hour heart rate variability in military populations. Sensors (Basel). 2021;21(4):1061.
37. Stone JD, Ulman HK, Tran K, Thompson AG, Halter MD, Ramadan JH, et al. Assessing the accuracy of popular commercial technologies that measure resting heart rate and heart rate variability. Front Sports Act Living. 2021;3:585870.
38. Natarajan A, Pantelopoulos A, Emir-Farinas H, Natarajan P. Heart rate variability with photoplethysmography in 8 million individuals: a cross-sectional study. Lancet Digit Health. 2020;2(12):e650-7.
39. Hickey BA, Chalmers T, Newton P, Lin CT, Sibbritt D, McLachlan CS, et al. Smart devices and wearable technologies to detect and monitor mental health conditions and stress: a systematic review. Sensors (Basel). 2021;21(10):3461.
40. Iqbal T, Elahi A, Ganly S, Wijns W, Shahzad A. Photoplethysmography-based respiratory rate estimation algorithm for health monitoring applications. J Med Biol Eng. 2022;42(2):242-52.
41. Chinoy ED, Cuellar JA, Huwa KE, Jameson JT, Watson CH, Bessman SC, et al. Performance of seven consumer sleep-tracking devices compared with polysomnography. Sleep. 2021;44(5):zsaa291.
42. Lim SE, Kim HS, Lee SW, Bae KH, Baek YH. Validation of Fitbit Inspire 2 against polysomnography in adults considering adaptation for use. Nat Sci Sleep. 2023;15:59-67.
43. Papini GB, Fonseca P, van Gilst MM, Bergmans JWM, Vullings R, Overeem S. Wearable monitoring of sleep-disordered breathing: estimation of the apnea-hypopnea index using wrist-worn reflective photoplethysmography. Sci Rep. 2020;10(1):13512.
44. Hayano J, Yamamoto H, Nonaka I, Komazawa M, Itao K, Ueda N, et al. Quantitative detection of sleep apnea with wearable watch device. PLoS One. 2020;15(11):e0237279.
45. US Food and Drug Administration. De Novo classification request: Samsung Sleep Apnea Feature, DEN230041 [Internet]. Silver Spring (MD): FDA; 2024 Feb 9 [cited 2026 May 22]. Available from: https://www.accessdata.fda.gov/cdrh_docs/pdf23/DEN230041.pdf
46. US Food and Drug Administration. 510(k) premarket notification: Apple Sleep Apnea Notification Feature, K240929 [Internet]. Silver Spring (MD): FDA; 2024 Sep 13 [cited 2026 May 22]. Available from: https://www.accessdata.fda.gov/cdrh_docs/pdf24/K240929.pdf
47. US Food and Drug Administration. Do not use smartwatches or smart rings to measure blood glucose levels: FDA safety communication [Internet]. Silver Spring (MD): FDA; 2024 Feb 21 [cited 2026 May 22]. Available from: https://www.fda.gov/medical-devices/safety-communications/do-not-use-smartwatches-or-smart-rings-measure-blood-glucose-levels-fda-safety-communication
48. Charlton PH, Paliakaitė B, Pilt K, Bachler M, Zanelli S, Kulin D, et al. Assessing hemodynamics from the photoplethysmogram to gain insights into vascular age: a review from VascAgeNet. Am J Physiol Heart Circ Physiol. 2022;322(4):H493-522.
49. Hasan MK, Aziz MH, Zarif MII, Hasan M, Hashem MMA, Guha S, et al. Noninvasive hemoglobin level prediction in a mobile phone environment: state of the art review and recommendations. JMIR Mhealth Uhealth. 2021;9(4):e16806.
50. Pollreisz D, TaheriNejad N. Detection and removal of motion artifacts in PPG signals. Mob Netw Appl. 2022;27(2):728-38.
51. Badan Kebijakan Pembangunan Kesehatan. Survei Kesehatan Indonesia (SKI) 2023 dalam angka. Jakarta: Kementerian Kesehatan Republik Indonesia; 2024.
52. Tondas AE, Halim RA, Felani MR, Caesarani FP, Puspita I, Toruan ML. Comparison of two smartphone-based atrial fibrillation screening application in an Indonesian tertiary care population. Indones J Cardiol. 2021;42(1). doi:10.30701/ijc.1066
53. Yuniadi Y, Supit AI, Hanafy DA, Raharjo SB, Hermanto DY, Basalamah F, et al. Prevalence of atrial fibrillation based on tertiary hospital survey in Indonesia: a smartphone-based diagnosis. J Arrhythm. 2024;40(5):1102-7.
54. Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Nomor 5 Tahun 2026 tentang Perbekalan Kesehatan [Minister of Health Regulation No. 5 of 2026 on Health Supplies]. Jakarta: Kementerian Kesehatan RI; 2026.
55. Republik Indonesia. Undang-Undang Nomor 27 Tahun 2022 tentang Pelindungan Data Pribadi [Law No. 27 of 2022 on Personal Data Protection]. Lembaran Negara Republik Indonesia Tahun 2022 Nomor 196. Jakarta: Sekretariat Negara; 2022.
56. Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Nomor 24 Tahun 2022 tentang Rekam Medis [Minister of Health Regulation No. 24 of 2022 on Medical Records]. Berita Negara Republik Indonesia Tahun 2022 Nomor 829. Jakarta: Kementerian Kesehatan RI; 2022.
57. Kementerian Kesehatan Republik Indonesia. Cetak biru strategi transformasi digital kesehatan 2024 [Blueprint for the 2024 digital health transformation strategy]. Jakarta: Kementerian Kesehatan RI; 2021.
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