Wearable ECG and PPG for Anxiety Detection: A Translational Digital Medicine Perspective

Wearable ECG and PPG for Anxiety Detection: A Translational Digital Medicine Perspective | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Wearable ECG and PPG for Anxiety Detection: A Translational Digital Medicine Perspective Mohamed Elgendi, Azza Elkhalifa, Noor Alhashmi, Alya Aldahmani, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8445330/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Apr, 2026 Read the published version in npj Digital Medicine → Version 1 posted 10 You are reading this latest preprint version Abstract Anxiety disorders affect hundreds of millions of people worldwide, yet objective and continuous assessment remains limited in clinical practice. Wearable electrocardiography (ECG) and photoplethysmography (PPG), combined with digital analytics, have emerged as promising tools for anxiety monitoring, but translation into routine care has been slow. Here, we present a PRISMA-guided systematic review of 38 studies (2015–2025) investigating wearable ECG- and PPG-based anxiety detection. We examine anxiety induction paradigms, sensor configurations, signal acquisition strategies, and analytical approaches, including statistical, machine learning, and hybrid methods. While autonomic markers derived from ECG and PPG consistently reflect anxiety-related physiological changes, substantial heterogeneity in study design, limited population diversity, and laboratory-centric validation constrain clinical generalizability. Critically, most studies lack evaluation in real-world settings and do not demonstrate clinical utility or impact on patient outcomes. We identify key translational barriers and propose a digital medicine roadmap emphasizing standardized protocols, robust validation across diverse populations, workflow integration, and outcome-driven evaluation to advance wearable anxiety monitoring toward clinical readiness. Health sciences/Biomarkers Biological sciences/Computational biology and bioinformatics Health sciences/Diseases Physical sciences/Engineering Health sciences/Health care Health sciences/Medical research Full Text Additional Declarations Competing interest reported. The authors declare no conflict of interest. M.E. serves as Associate Editor for npj biosensing and had no role in the peer-review or decision to publish this manuscript. Supplementary Files SupplementaryInformation1.pdf Cite Share Download PDF Status: Published Journal Publication published 13 Apr, 2026 Read the published version in npj Digital Medicine → Version 1 posted Editorial decision: Revision requested 02 Feb, 2026 Reviews received at journal 28 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviews received at journal 13 Jan, 2026 Reviewers agreed at journal 12 Jan, 2026 Reviewers invited by journal 12 Jan, 2026 Editor assigned by journal 29 Dec, 2025 Submission checks completed at journal 29 Dec, 2025 First submitted to journal 24 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8445330","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":573940984,"identity":"b159520a-659c-4930-b07e-e4a23d7b023f","order_by":0,"name":"Mohamed Elgendi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYFACHhDBzMDADqLZJOQkiNfCDNFiTLIWhsQZhDTotvce/HSjwpqBn5n94uOCMov0mTMSGD/8YLCTw6XF7My5ZOmcM+kMks08xcYzzknkzpZIYJbsYUg2xqnlRo6BdG7bYQaDwzxp0rxtErnzJBIYpIHuTGzArcX4d+6/wwz2h3nSfwO1pMsBbfnNwFBfj0eLmXRuA9AWZvZjzEAtCdISCWxAWw4n4PbLGTPrnGPpPBKHeZilec5JGM7sedhm2WNw3BCnLcd7jG/n1FjL8be3P/zMU1YnL3E8+fCNHxXV8rhsgQFg7PAYQNmMQPMN8CmGA/YHRCkbBaNgFIyCkQcAg1FLu4TiM08AAAAASUVORK5CYII=","orcid":"","institution":"Khalifa University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Elgendi","suffix":""},{"id":573940987,"identity":"ba99a678-af51-4af9-b3a8-f99697cd305d","order_by":1,"name":"Azza Elkhalifa","email":"","orcid":"","institution":"Khalifa University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Azza","middleName":"","lastName":"Elkhalifa","suffix":""},{"id":573940991,"identity":"704ae719-f190-4c8e-ad5b-b8398f8410f4","order_by":2,"name":"Noor Alhashmi","email":"","orcid":"","institution":"Khalifa University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Noor","middleName":"","lastName":"Alhashmi","suffix":""},{"id":573940994,"identity":"c92d2120-f30f-4681-8052-37035d9f9cf1","order_by":3,"name":"Alya Aldahmani","email":"","orcid":"","institution":"Khalifa University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Alya","middleName":"","lastName":"Aldahmani","suffix":""},{"id":573940997,"identity":"d0e2778f-7567-48b5-9fa6-b99447a33aa4","order_by":4,"name":"Noor Aljneibi","email":"","orcid":"","institution":"Khalifa University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Noor","middleName":"","lastName":"Aljneibi","suffix":""},{"id":573941000,"identity":"84e455b1-62b6-4304-9917-f5b05ac7bc2e","order_by":5,"name":"Dhabia Alamro","email":"","orcid":"","institution":"Khalifa University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Dhabia","middleName":"","lastName":"Alamro","suffix":""},{"id":573941009,"identity":"702316e4-5fa0-4398-95c8-802d921262b1","order_by":6,"name":"Herbert F. 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