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June 14, 2026Sports Medicine - OpenOpen Access

PPG-derived PRV underestimates ECG-derived HRV by ~23 ms, delaying detection of autonomic deterioration.

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Why the study?

Wearable devices often use photoplethysmography to calculate pulse rate variability rather than ECG-based heart rate variability, but agreement between the two has not been verified for tracking autonomic function in athletes.

Does photoplethysmography-derived pulse rate variability accurately agree with electrocardiogram-derived heart rate variability for tracking autonomic function in collegiate American football athletes?

Population

103 male, Division I collegiate American football athletes

Comparison

PPG-derived PRV vs ECG-derived HRV

Design

Cohort study

Follow-up

Three seasons

Key result

Photoplethysmography-derived pulse rate variability significantly underestimated electrocardiogram-derived heart rate variability (mean bias for rMSSD -23.0 ms) and exhibited a 1.8 to 5.5 day delay in detecting autonomic deterioration.

Authors

KBKfir Ben-DavidAKAllen B. KantrowitzMMMichael Morris

Discussion

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Overview

PRV from wearables cannot substitute ECG-derived HRV for athlete monitoring; leaves open need for device-specific validation in football cohorts.

Key Points

  • This research aims to evaluate the agreement between pulse rate variability (PRV) and heart rate variability (HRV) in athletes and its implications for performance monitoring.
  • Analyzed data from 103 Division I collegiate American football players over three seasons.
  • Used electrocardiogram (ECG) for HRV and photoplethysmography (PPG) for PRV measurements.
  • Employed Bland-Altman analysis and z-score threshold-crossing analysis to assess agreement and identify autonomic deviations.
  • PPG-PRV values were significantly lower than ECG-HRV for rMSSD (80.9 ms vs. 103.9 ms) and SDNN (141.3 ms vs. 167.9 ms).
  • PRV detected only 16.7% to 56.7% of HRV-identified events, and exhibited a delay of 1.8–5.5 days in recognizing autonomic changes.
  • Bland-Altman analysis indicated a high agreement between heart rate and pulse rate, with small bias (0.24–0.44 bpm), but substantial bias for PRV compared to HRV.

Study Design

Type

Cohort (n=103)

Multicenter

No

Structured PICO

Does photoplethysmography-derived pulse rate variability accurately agree with electrocardiogram-derived heart rate variability for tracking autonomic function in collegiate American football athletes?

P
Population
103 healthy male Division I collegiate American football athletes followed over 3 seasons to compare autonomic nervous system tracking via PPG-PRV versus ECG-HRV.
E
Exposure
Photoplethysmography (PPG) derived pulse rate variability (PRV) measured continuously via an armband monitor (Warfighter Monitor)
C
Comparator
Electrocardiogram (ECG) derived heart rate variability (HRV) measured continuously via the same armband monitor
O
Outcome
Agreement between PRV and HRV (rMSSD and SDNN) assessed using Bland-Altman analysis (bias, limits of agreement, and confidence intervals)surrogate

Main Result

Mean Difference: -23.004 (95% CI -23.126–-22.883)

Absolute Event Rate: 80.9% vs 103.9%

Photoplethysmography-derived pulse rate variability significantly underestimates electrocardiogram-derived heart rate variability and delays the detection of autonomic deterioration, indicating it is not an equivalent surrogate for tracking athlete autonomic function.

Limitations

  • Inclusion of only male athletes
  • Included athletes from only one collegiate sport (American football)
  • PPG was only measured on the upper arm, potentially restricting generalizability

Cite This Study

Ben-David et al. (2026) conducted a cohort in Healthy athletes (n=103). Photoplethysmography-derived pulse rate variability (PPG-PRV) vs. Electrocardiogram-derived heart rate variability (ECG-HRV) was evaluated on Agreement between PRV and HRV for rMSSD (Red PPG) (Mean bias -23.004 ms, 95% CI -23.126, -22.883). Photoplethysmography-derived pulse rate variability significantly underestimated electrocardiogram-derived heart rate variability (mean bias for rMSSD -23.0 ms) and exhibited a 1.8 to 5.5 day delay in detecting autonomic deterioration.

synapsesocial.com/papers/6a2e4753b1cc60ccdea8bdf7https://doi.org/10.1186/s40798-026-01027-8
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Pulse rate variability is not the same as heart rate variability: findings from a large, diverse clinical population study2025 · 13 citations
  2. 2Pulse rate variability: a new biomarker, not a surrogate for heart rate variability2020 · 93 citations
  3. 3Assessing Heart Rate Variability and Pulse Rate Variability Patterns in Cardiac Patients: Exploring the Utility of Photoplethysmography and Electrocardiography2024 · 5 citations
  4. 4Association of Heart rate variability measured by RR interval from ECG and pulse to pulse interval from Photoplethysmography2021 · 36 citations
  5. 5Electrocardiogram and Photoplethysmogram-based Heart Rate Variability Are Not Equivalent: A Bayesian Simulation Analysis2023 · 2 citations