Therapeutic use of music listening in patients undergoing invasive coronary procedures: A meta-analysis

Abstract

BACKGROUND

Listening to music has been shown to reduce pain and anxiety before, during, and after invasive coronary procedures.

AIM

To perform a systematic review and meta-analysis to explore the effect of therapeutic use of music on both, perioperative and postoperative outcomes of invasive coronary procedures.

METHODS

An exhaustive literature search of 3 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL) was conducted from inception until 10^th December 2023. The results of our analyses are presented as standard mean difference (SMD) or weighted mean difference, with 95%CI and pooled using a random effects model. A P value < 0.05 was considered significant in all cases.

RESULTS

From 21 studies, 2141 participants were included in our analysis. The pooled analysis demonstrated that music listening significantly improves post-procedural pain (SMD = -0.78, 95%CI: -1.34 to -0.23; P = 0.006), anxiety (SMD = -0.86, 95%CI: -1.43 to -0.29; P = 0.003), heart rate [mean difference (MD) = -3.38, 95%CI: -5.51 to -1.25; P = 0.002], and systolic blood pressure (MD = -5.89, 95%CI: -9.75 to -2.02; P = 0.003). There was no significant improvement in diastolic blood pressure (MD = -3.22, 95%CI: -6.58 to 0.14; P = 0.06) or respiratory rate (MD = -0.97, 95%CI: -1.98 to 0.03; P = 0.06).

CONCLUSION

Music listening can be used in healthcare settings for patients undergoing invasive coronary procedures to reduce anxiety levels and improve their physiological parameters.

Key Words: Music; Music therapy; Percutaneous coronary intervention; Coronary artery bypass grafting; Angiography; Anxiety; Pain management

Core Tip: This meta-analysis evaluated the therapeutic effects of music listening on patients undergoing invasive coronary procedures such as percutaneous coronary intervention and coronary artery bypass grafting. The study demonstrated that music therapy significantly reduces post-procedural anxiety, heart rate, systolic blood pressure and pain levels. These findings highlight the potential use of music as a non-pharmacological intervention to improve patient outcomes and well-being in healthcare settings, making it a valuable complementary treatment for managing the psychological and physiological stress associated with invasive cardiac procedures.

INTRODUCTION

The leading cause of mortality is coronary heart disease (CHD), accounting for approximately 9.5 million deaths globally[1]. Coronary procedures are an effective treatment for CHD as they facilitate the removal of blood clots, which increases myocardial blood flow[2]. However, invasive procedures such as angiography and percutaneous coronary intervention (PCI) result in serious anxiety, panic, and mental stress[3,4]. The physiological response of the body to stress is anxiety, which is characterized by elevated levels of serum adrenaline, heart rate (HR), respiratory rate (RR), blood pressure (BP), and decreased pain threshold[5]. Elevated HR and BP during invasive cardiovascular procedures enhance the cardiac strain and treatment risk[6,7]. In order to mitigate anxiety and pain both before and after such invasive procedures, several strategies have been devised. Among these is a non-pharmacological technique such as music listening[3,8].

For thousands of years, people have recognized the therapeutic effects of music[9]. However, how music impacts the human body is not entirely understood. The majority of theories postulate that music affects the autonomic and central nervous systems at subcortical levels in addition to being perceived consciously and that the limbic system is essential for processing musical aspects[10]. In addition to assessing the levels of stress and anxiety during cardiac procedures, several studies have examined the impact of music listening on cardiovascular outcomes such as BP and HR. Although these outcomes were previously investigated in a previous meta-analysis[11], it included only 10 studies and concluded its search in 2019. Given the recent expansion of literature in this area, an update to these results was long overdue. Therefore, to address this literature gap, we conducted a systematic review and meta-analysis to investigate the impact of music therapy on CHD patients undergoing coronary procedures. In this study, music therapy refers to the intentional use of music by healthcare providers to promote patient’s psychological and physiological well-being. Music therapy, particularly in clinical settings, is often used to complement conventional treatments to alleviate stress, anxiety and pain. This non-invasive and non-pharmacological intervention has shown efficacy in various medical contexts, including cardiac care, by helping patients relax and manage emotional and physiological responses to invasive procedures.

MATERIALS AND METHODS

This systematic review and meta-analysis followed the recommended reporting format specified in the Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines[12]. Permission from the Institutional Review Board was not required as data used in this study were publicly available.

Data source and search strategy

An electronic search of the MEDLINE, Scopus, and Cochrane CENTRAL databases was carried out from inception until 10^th December 2023. The search string used consisted of the following keywords and related Medical Subject Headings terms: ((((((music therapy) AND (coronary procedures)) OR (percutaneous coronary intervention)) OR (PCI)) OR (coronary artery bypass grafting)) OR (CABG)) OR (cardiac catheterization). The retrieved studies that met the eligibility criteria were included in this meta-analysis. No language limitations were imposed while searching the literature. Further studies were found by manually searching references in past meta-analyses, reviews, and published articles. Two researchers (Shafiq A and Ahmed M) carried out the literature search, study selection, and data extraction independently. In the event of any disagreements, a third reviewer (Shafiq A) was consulted. It is important to note that the studies included in this review utilize music listening, which involves the provision of pre-recorded music for patients. This is distinct from music therapy, a structured intervention led by credentialed music therapists, which involves individualized, therapeutic use of music tailored to the patient's needs. The studies included in this review focus on music listening, facilitated by healthcare providers or self-administered by patients.

Study selection

The eligibility requirements were as follows: (1) Published clinical trials, both randomized and non-randomized; (2) Participants who were at least eighteen years old with an indication for PCI, coronary angiography, coronary artery bypass grafting (CABG) or vascular angiography; (3) Details of the music intervention that was used; and (4) Outcomes measured included anxiety, pain, HR, systolic BP (SBP), diastolic BP (DBP) and RR. Literature reviews, case reports, case series, animal studies, interventional trials without music listening, and studies with fewer than five patients were excluded.

Data extraction and risk of bias assessment

Articles yielded through a search of the databases were exported to EndNote where they were checked for duplicates. Following the elimination of duplicates, papers were individually evaluated and screened based on title and abstract. Using the previously mentioned eligibility criteria, the remaining studies were further shortlisted. The quality of the non-randomized studies used in this meta-analysis was assessed using the Cochrane Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool[13]. The ROBINS-I tool uses seven domains to determine overall bias in each non-randomized clinical trial. Studies were classified as having low, moderate, serious, or critical risk of bias. Trials that had information missing in one or more domains were classified as no information. All randomized controlled trials were assessed for risk of bias using the Cochrane Risk of Bias 2 tool. Five domains were used to evaluate the studies: (1) Randomization; (2) Deviation from intended interventions; (3) Missing outcome data; (4) Outcome measurement; and (5) Selection of reported results. Based on the Risk of Bias tool, each randomized controlled trial (RCT) was classified as having a high risk of bias, some concerns, or a low risk of bias.

Statistical analysis

All statistical analyses were conducted using RevMan (version 5.4.1; Copenhagen: The Nordic Cochrane Collaboration, 2014). The random effects model was used to pool the data for the following outcomes: (1) Anxiety; (2) Pain; (3) RR; (4) SBP; (5) DBP; and (6) HR. Except for pain and anxiety, which are reported as standard mean difference (SMD), all outcomes are presented as weighted mean difference with 95%CI. In each case, results were deemed statistically significant if the P value was less than or equal to 0.05. The Higgins I² test was used to investigate heterogeneity. It was determined that an I² value of 25%–50% was mild, 50%–75% was moderate, and > 75% was severe. Analysis was conducted based on outcome measurements reported in each study at any time, before the procedure, during the procedure, and after the procedure across the control and intervention groups.

RESULTS

We performed a comprehensive literature search using PubMed/MEDLINE, EMBASE, and the Cochrane Library. The initial search yielded 342 records. The duplicate studies were removed, and articles were screened based on the study title and abstract. The full text of 73 studies was reviewed and a total of 21 studies were considered eligible for inclusion in our meta-analysis. The details of the literature search and study selection process are shown in the PRISMA flowchart of Figure 1.

Figure 1  Preferred Items for Systematic Reviews and Meta-Analysis flowchart summarizing results of the literature search.

A total of 21 studies[3,8,14-32] were included in our pooled analysis. The included studies were published from 1995 to 2023. There was variability in the study design of pooled articles that included 11 RCTs and 10 non-randomized studies. A total of 2141 patients were included in our pooled analysis. The mean age of patients ranged from 18 years to 74 years. Seven studies were conducted in the United States[18-21,27,28,32], 5 in Iran[3,8,14,26,31], 2 in Turkey[16,17], 2 in China[15,30], 2 in Sweden[24,25], 2 in Hong Kong[22,29] and 1 in Germany[23]. The detailed baseline characteristics of the included studies are provided in Table 1[3,8,14-32].

Table 1 The detailed baseline characteristics of the included studies.

Ref.	Country	Year	N	Sex (male/female)	Age (intervention/control)	Type of study	Type of music	Tempo (beats/minute)	Lyrics	Duration (minute)	Time of intervention	Mode of delivery	Outcome
Moradipanah et al[14]	Iran	2009	74	37/37	Mean = 50.6	RCT	Slow and steady rhythms	60-80	No	20	Before angiography	Earphones plugged to a cassette	Anxiety (DASS-21 score)
Dong et al[15]	China	2023	86	50/36	Mean = 57.6/54.8	RCT	Low-key music	60-80	-	15	2 hours after extubation	Binaural headphones	Pain (VAS), anxiety (STAI), HR, SBP, DBP, RR
Oyur Çelik et al[16]	Turkey	2022	62	31/31	Mean = 58.58/56.81	RCT	Instrumentaland Nihavend mode	-	No	45	Before coronary angiography	Music CD	Pain (VAS), anxiety (STAI), HR, SBP, DBP, RR
Doğan and Şenturan[17]	Turkey	2012	200	140/60	Range = 18-66	Pretest/posttest control group	Calming and relaxing and Huseyni mode	-	No	-	During coronary angiography	CD player	Anxiety (STAI score)
Forooghy et al[8]	Iran	2015	64	41/23	Range = 45-82	RCT	Light instrumental by Bach	-	No	20-40	Before coronary angioplasty	MP3 player and headphones	Anxiety (STAI), SBP, DBP, RR, HR
Zimmerman et al[18]	United States	1996	96	64/30	Mean = 67	Repeated measures experiment	Participant's choice	-	No	30	Post CABG	Headphones	Pain (VRS, McGill pain questionnaire score)
Bally et al[19]	United States	2003	107	64/49	Mean = 59/58	Pretest-posttest control group	Self-selected by patient	-	-	-	Before, during or after coronary angiography	Headphones and cassette recorder	Anxiety (STAI), pain (VAS), HR, SBP, DBP
Rejeh et al[3]	Iran	2016	130	64/66	Mean = 61.68	Quasi-randomized controlled trial	Pleasant natural sounds	-	-	-	30 minutes before coronary angiography	MP3 player and foam-lined headphones	Anxiety (STAI), SBP, DBP, RR, HR
Hamel et al[20]	United States	2001	101	63/38	Range = 43-74	Quasi-experimental	ÄòTrance‚ ÄìZendance‚Äô by Halpern	70-80	No	20	Prior to cardiac catheterization	Portable CD player	Anxiety (STAI), HR, BP
Cadiganv et al[21]	United States	2001	140	100/40	Mean = 62.2	RCT	Mixture of symphonic music and nature sounds	-	No	30	Post PCI or on bedrest	CD player and headphones	Pain (VAS), SBP, DBP, HR, RR
Taylor-Piliae et al[22]	Hong Kong (China)	2002	45	23/7	Mean = 58.2	Experimental three-group	New age and Chinese instrumental or classical	-	No	-5	1 hour prior to catheterization	Cassette recorder and headphones	Anxiety (SAI), HR, RR
Argstatter et al[23]	Germany	2006	90	31/24	Mean = 66.5	Pretest-posttest, three-armed	ÄúRelaxation‚ Äù by Martin Rumme	-	-	-	During cardiac catheterization	Earphones	Anxiety (STAI), HR, SBP, DBP
Nilsson[25]	Sweden	2012	68	0/68	Mean = 67/65	RCT	Soft and relaxing musicure	60-80	No	-	During coronary angiography and/or PCI	Maysound music player	Anxiety (NRS)
Nilsson[24]	Sweden	2009	238	119/119	Mean = 67/64	RCT	Soft and relaxing musicure	60-80	No	-	During coronary angiography and/or PCI	Maysound music player	Anxiety (STAI, NRS), pain (VAS)
Amiri et al[26]	Iran	2017	90	56/34	Mean = 58.61	RCT	ÄúSounds of Nature and Äù by Stein A	-	No	30	Before CABG	Sony MP3 player	Anxiety (STAI)
Barnason et al[27]	United States	1995	96	65/31	Mean = 67	Repeated measures and quasi-experimental	Participant's choice	-	No	30	Post-operative day 2 and 3 after CABG	Headphones	Anxiety (NRS, STAI), SBP, DBP, HR
Buffum et al[28]	United States	2006	170	166/4	Mean = 67.01/66.65	Quasi-experimental	Classical, jazz, rock, country western, and easy listening	-	-	15	Before vascular angiography	Boombox style CD player without headphones	Anxiety (STAI), SBP, DBP, RR, HR
Chan[29]	Hong Kong (China)	2006	43	31/12	Range = 35-75	RCT	Soft and slow music	-	No	45	During C-clamp procedure	MP3 player with headphones	Pain (University of California Los Angeles), SBP, DBP, HR, RR
Dai et al[30]	China	2020	99	37/29	Mean = 53.4/53.1	Retrospective study	Light and relaxing	-	-	30	After coronary bypass	Binaural headphones	Pain (NRS), anxiety (SAS)
Heidari et al[31]	Iran	2015	60	33/27	Mean = 56.33/60.91	RCT	Sounds of nature	-	-	30	Before CABG	Digital MP3 player with headphones	Anxiety (VAS-A), HR, SBP, DBP
Twiss et al[32]	United States	2006	86	28/58	Mean = 72.6/75.1	RCT	Choice between six relaxing CDs	-	-	-	Throughout CABG procedure and post-op	Headphones	Anxiety (STAI)

CABG: Coronary artery bypass grafting; DBP: Diastolic blood pressure; HR: Heart rate; NRS: Numerical Rating Scale; PCI: Percutaneous coronary intervention; RCT: Randomized control trial; RR: Respiratory rate; SBP: Systolic blood pressure; STAI: State anxiety inventory; VAS: Visual Analogue Scale.

The quality assessment of included RCTs was performed using the Cochrane risk of bias tool and ROBINS-I was used for non-randomized studies. The details of bias assessment for each included study are provided in Supplementary Table 1[8,14-16,21,24-26,29,31,32] and Supplementary Table 2[3,15,18-20,22,23,27,28,30].

Results of meta-analysis

Anxiety: Data for anxiety at any time was reported by 15 studies. Our pooled analysis showed that anxiety at any time was significantly reduced in the music listening group (SMD = -0.86, 95%CI: -1.43 to -0.29; P = 0.003) (Figure 2A). High heterogeneity was observed (I² = 96%). No significant difference was observed between the music listening and the control group for pre-procedural anxiety (SMD = -0.14, 95%CI: -0.48 to 0.20; P = 0.41, I² = 60%) (Figure 2B). Music listening was associated with significantly reduced post-procedural anxiety (SMD = -0.92, 95%CI: -1.45 to -0.39; P = 0.0007, I² = 92%) (Figure 2C)[3,14-17,19,20,22,24-28,30-32].

Figure 2 Effect of music therapy on anxiety. A: Forest plot of anxiety at any time; B: Forest plot of pre-procedural anxiety; C: Forest plot of post-procedural anxiety.

SBP: Ten studies provided data for SBP at any time. Our pooled analysis demonstrated that SBP at any time was significantly reduced in patients who were in the music listening group [mean difference (MD) = -5.89, 95%CI: -9.75 to -2.02; P = 0.003] (Figure 3A). Moderate heterogeneity was observed (I² = 71%). Pre-procedural SBP was comparable across the two groups (MD = 0.55, 95%CI: -12.37 to 13.48; P = 0.93, I² = 83%) (Figure 3B). No significant difference was observed for procedural SBP (MD = -7.93, 95%CI: -16.70 to 0.84; P = 0.08, I² = 0%) (Figure 3C). Music listening resulted in a significantly reduced post-procedural SBP (MD = -7.95, 95%CI: -11.42 to -4.48; P ≤ 0.00001, I² = 57%) (Figure 3D)[3,8,15,16,20,21,23,28,29,31].

Figure 3 Effect of music therapy on systolic blood pressure. A: Forest plot of systolic blood pressure (BP) at any time; B: Forest plot of pre-procedural systolic BP; C: Forest plot of procedural systolic BP; D: Forest plot of post-procedural systolic BP.

DBP: Data for DBP at any time was reported by 10 studies. There was no significant difference between the music listening and the control group for DBP at any time (MD = -3.22, 95%CI: -6.58 to 0.14; P = 0.06) (Figure 4A). High heterogeneity was observed (I² = 82%). No significant difference was observed for pre-procedural DBP (MD = -1.08, 95%CI: -3.90 to 1.74;P = 0.45, I² = 0%) (Figure 4B), procedural DBP (MD = 0.42, 95%CI: -3.83 to 4.67; P = 0.85, I² = 0%) (Figure 4C) and post-procedural DBP (MD = -4.89, 95%CI: -9.93 to 0.14; P = 0.06, I² = 88%) (Figure 4D)[3,8,15,16,20,21,23,28,29,31].

Figure 4 Effect of music therapy on diastolic blood pressure. A: Forest plot of diastolic blood pressure (BP) at any time; B: Forest plot of pre-procedural diastolic BP; C: Forest plot of procedural diastolic BP; D: Forest plot of post-procedural diastolic BP.

HR: Data for HR at any time was reported by 11 studies. HR at any time was significantly reduced in the music listening group (MD = -3.38, 95%CI: -5.51 to -1.25; P = 0.002) (Figure 5A). Moderate heterogeneity was observed (I² = 45%). The pooled analysis showed no significant difference for pre-procedural HR (MD = -2.38, 95%CI: -5.47 to 0.72; P = 0.13, I² = 31%) (Figure 5B) and procedural HR (MD = -5.10, 95%CI: -18.91 to 8.71; P = 0.47, I² = 86%) (Figure 5C). Post-procedural HR was significantly reduced in patients who were in the music listening group (MD = -3.62, 95%CI: -6.00 to -1.24; P = 0.003, I² = 21%) (Figure 5D)[8,15,16,20-24,28,29,31].

Figure 5 Effect of music therapy on heart rate. A: Forest plot of heart rate (HR) at any time; B: Forest plot of pre-procedural HR; C: Forest plot of procedural HR; D: Forest plot of post-procedural HR.

RR: Data for RR at any time was provided by 8 studies. Our pooled analysis showed that there was no significant difference between the two groups for RR at any time (MD = -0.97, 95%CI: -1.98 to 0.03; P = 0.06) (Figure 6A). Moderate heterogeneity was observed (I² = 74%). No significant changes were observed for pre-procedural RR (MD = -0.05, 95%CI: -1.24 to 1.13;P = 0.93, I² = 25%) (Figure 6B) and post-procedural RR (MD = -0.86; 95%CI: -2.02 to 0.31; P = 0.15, I² = 73%) (Figure 6C)[8,15,16,21,22,24,28,29].

Figure 6 Effect of music therapy on respiratory rate. A: Forest plot of respiratory rate (RR) at any time; B: Forest plot of pre-procedural RR; C: Forest plot of post-procedural RR.

Pain: Six studies reported data for post-procedural pain. Our pooled analysis showed that music listening significantly reduced post-procedural pain (SMD = -0.78, 95%CI: -1.34 to -0.23; P = 0.006) (Figure 7)[15,16,18,19,24,30]. High heterogeneity was observed (I² = 87%).

Figure 7  Forest plot of post-procedural pain.

DISCUSSION

Our systematic review and meta-analysis of 21 studies evaluated the therapeutic effect of music on patients undergoing invasive cardiac surgeries. Our pooled analysis of results from 2141 participants demonstrated significant improvements in post-procedural pain, anxiety, HR, and SBP. However, we discovered no significant difference in DBP and RR. A central illustration summarizing the findings of our study is provided in Figure 8.

Figure 8  Central illustration summarizing the findings of our meta-analysis.

Our study focused on music therapy, defined as the clinical and evidence-based use of music interventions to accomplish individualized therapeutic goals. This includes managing symptoms such as anxiety, pain, and stress, which are prevalent in patients undergoing invasive cardiac procedures. Music therapy can be self-administered by patients through pre-selected playlists or conducted with the support of a music therapist, who tailors the intervention to patient’s specific emotional and physiological needs. This approach is grounded in both physiological theories and neurological evidence, which suggests that music interacts with the brain’s limbic and autonomic systems to modulate stress and emotional responses.

Our findings differed substantially from the previous meta-analysis[11]. In contrast to our results, the previous meta-analysis demonstrated the non-significance of music listening in improving post-procedural pain, HR, SBP, and DBP. The significant improvement observed in anxiety in previous studies was comparable to the findings of our meta-analysis. These discrepancies were noted because our analysis included many high-powered, previously missed published studies that had not been included in any of the prior analyses. Our study also considered some additional outcomes, such as RR, which have not been explored in the previous meta-analysis[11]. Hence, considering it is the most comprehensive and up-to-date analysis, this gives our study more statistical ability to produce the most precise and accurate assessments of impact sizes within the scope of the present literature.

Our results are consistent with other studies by Shum et al[33] and Lai and Good[34] that discovered that listening to music can regulate bodily rhythms by slowing them down. Consequently, this results in a decline in the body's noradrenaline levels and sympathetic nervous system[35]. This physiological shift causes the body to encourage profound relaxation and serenity, which lowers anxiety, HR, and BP. Nurses may readily facilitate music listening by providing pre-recorded music for patients, but this is distinct from music therapy, which requires the involvement of a credentialed music therapist[19]. The findings of our pooled analysis offer additional proof of this as patients undergoing invasive cardiac surgeries have less anxiety and improved physiological findings when listening to music as an intervention.

The current research can be utilized to direct clinical procedures and raise the standard of care provided to patients having coronary angiography or PCI. For music intervention supplied during the treatment, appropriate intervention settings (kind, pace, volume, duration, and listening equipment) and music providers can be created. Inquiring about the patient's preferred music for relaxation during pre-operative care may allow nurses to play similar music in the catheterization room before invasive cardiac procedures. If patients' choices, rather than the preferences of researchers or surgeons, are taken into consideration when selecting music, we anticipate that the effects of music intervention may be more noticeable. To encourage research endeavors and a more individualized approach to choosing music that suits patients' preferences, the hospital may include a licensed music therapist in the surgery team. To ensure that patients receive tailored music interventions that align with their therapeutic needs, a licensed music therapist can collaborate with the healthcare team to create personalized playlists. This approach respects the expertise of music therapists and allows nurses to focus on their core responsibilities while supporting non-pharmacological interventions. Nevertheless, further research is needed to ascertain if and how using a music therapist influences the effectiveness of music intervention.

To the best of our knowledge, this meta-analysis represents the most comprehensive and current examination of the role of the therapeutic use of music in patients undergoing invasive cardiac procedures. This enables us to derive reliable conclusions from our pooled investigation as well as the most precise and dependable assessments of the impact sizes. Previous research in this area was constrained by a smaller data set and a more constrained range of results. Additionally, in contrast to the previous meta-analysis, we observed significant results for most of our outcomes.

While our study had certain strengths, there were some limitations that we encountered when performing the meta-analysis. Firstly, different studies reported the observed outcomes at different times, pre-procedural, post-procedural, and at any given time. This discrepancy was resolved by generating a subgroup analysis of all three instances. Secondly, significant heterogeneity was observed in all our outcomes. This could be attributed to the different types of music, mode of delivery, differences in patient population and their baseline characteristics, and time of intervention used. Additionally, this meta-analysis included 21 studies from seven different countries: (1) United States; (2) China; (3) Iran; (4) Turkey; (5) Sweden; (6) Germany; and (7) Hong Kong (China). Coronary procedures such as PCI and CABG are common treatments for coronary artery disease, but the characteristics of patients undergoing these procedures can differ significantly across regions due to differences in healthcare systems, socioeconomic status, and lifestyle choices. For example, in the United States and Western European countries such as Germany and Sweden, advanced coronary care is widely available, and patients frequently obtain prompt procedures. These nations have aging populations and a greater prevalence of coronary artery disease risk factors including hypertension and diabetes, which may impact procedure results as well as patient responsiveness to non-pharmacological therapies like music listening. In contrast, patient populations in Iran, Turkey, and China may have greater disparity in healthcare availability, particularly in rural regions. Cultural variables influence how nontraditional treatments, such as music listening, are perceived and integrated into care. For example, the music utilized in research from Iran and Turkey may have cultural meaning, perhaps influencing anxiety and pain results differently than in Western countries. Considering these differences, the generalizability of our findings may vary based on the population and healthcare context. While the therapeutic use of music has demonstrated consistent effects on anxiety and pain across diverse settings, the extent to which these results can be broadly applied may depend on the specific demographics and cultural backgrounds of the patients.

Last but not the least, our study focused exclusively on anxiety and does not include other psychological outcomes such as depression. We chose to examine anxiety as the primary psychological outcome for several reasons. First, anxiety is a well-documented response to invasive cardiac procedures and is frequently associated with worsened physiological parameters such as elevated HR and BP. This makes anxiety a key factor that can directly affect the success and outcomes of cardiac interventions. Anxiety also has a significant impact on patient’s perception of pain, thus exacerbating discomfort during and after procedures. By focusing on anxiety, our study aims to target a modifiable psychological factor that can lead to broader improvements in both, emotional well-being and physical health outcomes in patients undergoing invasive cardiac procedures. While depression and other psychosocial parameters are also relevant, anxiety is typically the most immediate and acute response to the stress of surgery, which made it the most logical focus of our analysis.

We acknowledge that research shows differences in outcomes between researcher-selected and patient-selected music in music listening interventions. While the studies included in our analysis did not consistently specify the method of music selection, this distinction could influence outcomes, as patient-preferred music may enhance relaxation and emotional engagement more effectively than researcher-selected music. Further research in this area would be beneficial to clarify the role of music selection in optimizing therapeutic outcomes.

CONCLUSION

Patients having cardiac surgery who already struggle with one or more psychological issues need special consideration. We discovered sufficient evidence in our study to validate the effectiveness of music listening interventions in improving anxiety, post-procedural pain, HR, and SBP, but not for improving RR and DBP. Therefore, therapeutic use of music can be used in healthcare settings to lower patients' anxiety levels and improve their physiological parameters.