Accuracy of Photoplethysmography-Derived Pulse Rate Variability Compared with Electrocardiography-Derived Heart Rate Variability: A Systematic Review and Meta-Analysis

Photoplethysmography-derived pulse rate variability (PPG-derived PRV) is increasingly used in wearable and camera-based biomedical sensors as a low-burden alternative to electrocardiography-derived heart rate variability (ECG-derived HRV), but its agreement with ECG-derived measurements remains uncertain. This systematic review and meta-analysis evaluated the accuracy of PPG-derived PRV compared with ECG-derived HRV in healthy or apparently healthy non-clinical populations, focusing on the root mean square of successive differences (RMSSD) and the standard deviation of normal-to-normal intervals (SDNN). Forty-three studies were included in the qualitative synthesis; 33 were summarized narratively, and 10 unique studies provided sufficient data for quantitative synthesis. Eight studies contributed to each RMSSD and SDNN meta-analysis. The pooled absolute standardized error was 0.188 (95% CI: 0.066 to 0.309; I2 = 11.69%) for RMSSD and 0.134 (95% CI: 0.014 to 0.255; I2 = 0%) for SDNN. Sensitivity analyses supported the robustness of RMSSD findings, whereas SDNN estimates were directionally stable but less robust in statistical significance. Because the quantitative synthesis included only 10 studies and was based predominantly on selected resting or controlled conditions, the pooled estimates should not be generalized to sleep, exercise, stress, or free-living settings or interpreted as evidence of interchangeability.