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Heart rate variability (HRV) in deep breathing tests and 5-min short-term recordings: agreement of ear photoplethysmography with ECG measurements, in 343 subjects

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We analyzed heart rate variability (HRV) taken by ECG and photoplethysmography (PPG) to assess their agreement. We also analyzed the sensitivity and specificity of PPG to identify subjects with low HRV as an example of its potential use for clinical applications.


The HRV parameters: mean heart rate (HR), amplitude, and ratio of heart rate oscillation (E–I difference, E/I ratio), RMSSD, SDNN, and Power LF, were measured during 1-min deep breathing tests (DBT) in 343 individuals, followed by a 5-min short-term HRV (s-HRV), where the HRV parameters: HR, SD1, SD2, SDNN, Stress Index, Power HF, Power LF, Power VLF, and Total Power, were determined as well. Parameters were compared through correlation analysis and agreement analysis by Bland–Altman plots.


PPG derived parameters HR and SD2 in s-HRV showed better agreement than SD1, Power HF, and stress index, whereas in DBT HR, E/I ratio and SDNN were superior to Power LF and RMSSD. DBT yielded stronger agreement than s-HRV. A slight overestimation of PPG HRV over HCG HRV was found. HR, Total Power, and SD2 in the s-HRV, HR, Power LF, and SDNN in the DBT showed high sensitivity and specificity to detect individuals with poor HRV. Cutoff percentiles are given for the future development of PPG-based devices.


HRV measured by PPG shows good agreement with ECG HRV when appropriate parameters are used, and PPG-based devices can be employed as an easy screening tool to detect individuals with poor HRV, especially in the 1-min DBT test.

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Deep breathing test




Difference between the highest and the lowest heart rate within a breathing cycle


Heart rate


High frequency (0.15–0.4 Hz)


Heart rate variability




Low frequency (0.04–0.15 Hz)




Obstetrics and Gynecology




Root means square of successive differences

RR interval:

Time between two adjacent heart beats


Respiratory sinus arrhythmia


Standard deviation


“Width” of the Poincare plot, reflecting short term variability


“Length” of the Poincare plot, reflecting short term variability


Standard deviation of the RR-intervals


5-min short-term HRV measurement


Very low frequency


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We thank medical students Hanna Wisseler and Katharina Hennrich, Medical School University of Heidelberg, for their assistance in gathering patient data. We would like to express our gratitude to medical student Christina Armstrong for her excellent help in correcting the English text.

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Correspondence to Stefan W. Weinschenk.

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We declare that our experiments comply with the current German laws.

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R. D. Beise is an employee of Biosign GmbH, Germany. S. W. Weinschenk and J. Lorenz have no conflicts of interests.

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Communicated by Keith Phillip George.

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Weinschenk, S.W., Beise, R.D. & Lorenz, J. Heart rate variability (HRV) in deep breathing tests and 5-min short-term recordings: agreement of ear photoplethysmography with ECG measurements, in 343 subjects. Eur J Appl Physiol 116, 1527–1535 (2016).

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