Signal-Derived Feature Analysis for Cuffless Blood Pressure Estimation: Comparing Machine Learning and Deep Learning on ICU Physiological Waveforms

Irina Naskinova, Mikhail Kolev, Mariyan Milev, Penko Mitev

Continuous non-invasive blood pressure monitoring holds significant promise for cardiovascular disease management, yet cuff-based methods remain limited by their intermittent nature. Machine learning approaches leveraging photoplethysmography (PPG) and electrocardiography (ECG) signals present compelling alternatives, though questions persist about which signal type contributes more predictive value. This study compares traditional machine learning models, ensemble methods, and deep learning architectures for estimating systolic blood pressure from physiological waveforms. We extracted 55 features from PPG and ECG recordings of 100 subjects in the MIMIC-III Waveform Database, yielding 3000 segments with invasive arterial blood pressure as ground truth. Data splitting was performed at the subject level (70/15/15 train/validation/test) to prevent data leakage. Evaluation included regression metrics, British Hypertension Society grading, SHAP-based explainability, and ablation studies. Among all models, LightGBM achieved the best performance with mean absolute error of 15.97 mmHg, placing it at BHS Grade D. While SHAP analysis showed ECG features contributing 54.7% of importance versus 45.3% for PPG, our ablation study revealed that PPG-only models achieved comparable performance (MAE 15.97 vs. 16.23 mmHg), with the difference not statistically significant (p = 0.226). These results suggest that PPG-only wearable devices are viable for blood pressure estimation, as adding ECG features provides no statistically significant improvement. However, all configurations achieved only BHS Grade D, indicating that personalized calibration may be necessary for clinical acceptability.