Background
Individuals with coronary heart disease (CHD) often suffer from severe distress due to diagnosis, hospitalization, surgical procedures, uncertainty of outcome, fear of dying, doubts about progress in recovery, helplessness and loss of control. Such adverse effects put the cardiac patient at greater risk for complications, including sudden cardiac death. It is therefore of crucial importance that the care of people with CHD focuses on psychological as well as physiological needs.

Music interventions have been used to reduce anxiety and distress and improve physiological functioning in medical patients; however its efficacy for people with CHD needs to be evaluated.

Objectives
To update the previously published review that examined the effects of music interventions with standard care versus standard care alone on psychological and physiological responses in persons with CHD.

Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2012, Issue 10), MEDLINE (OvidSP, 1950 to October week 4 2012), EMBASE (OvidSP, 1974 to October week 5 2012), CINAHL (EBSCOhost, 1982 to 9 November 2012), PsycINFO (OvidSP, 1806 to October week 5 2012), LILACS (Virtual Health Library, 1982 to 15 November 2012), Social Science Citation Index (ISI, 1974 to 9 November 2012), a number of other databases, and clinical trial registers. We also conducted handsearching of journals and reference lists. We applied no language restrictions.

Selection criteria
We included all randomized controlled trials and quasi-randomized trials that compared music interventions and standard care with standard care alone for persons with confirmed CHD.

Data collection and analysis
Two review authors independently extracted data and assessed methodological quality, seeking additional information from the trial researchers when necessary. We present results using weighted mean differences for outcomes measured by the same scale, and standardized mean differences for outcomes measured by different scales. We used post-intervention scores. In cases of significant baseline difference, we used change scores (changes from baseline).

Main results
We identified four new trials for this update. In total, the evidence for this review rests on 26 trials (1369 participants). Listening to music was the main intervention used, and 23 of the studies did not include a trained music therapist.

Results indicate that music interventions have a small beneficial effect on psychological distress in people with CHD and this effect is consistent across studies (MD = -1.26, 95% CI -2.30 to -0.22, P = 0.02, I² = 0%). Listening to music has a moderate effect on anxiety in people with CHD; however results were inconsistent across studies (SMD = -0.70, 95% CI -1.17 to -0.22, P = 0.004, I² = 77%). Studies that used music interventions in people with myocardial infarction found more consistent anxiety-reducing effects of music, with an average anxiety reduction of 5.87 units on a 20 to 80 point score range (95% CI -7.99 to -3.75, P < 0.00001, I² = 53%). Furthermore, studies that used patient-selected music resulted in greater anxiety-reducing effects that were consistent across studies (SMD = -0.89, 95% CI -1.42 to -0.36, P = 0.001, I² = 48%). Findings indicate that listening to music reduces heart rate (MD = -3.40, 95% CI -6.12 to -0.69, P = 0.01), respiratory rate (MD = -2.50, 95% CI -3.61 to -1.39, P < 0.00001) and systolic blood pressure (MD = -5.52 mmHg, 95% CI - 7.43 to -3.60, P < 0.00001). Studies that included two or more music sessions led to a small and consistent pain-reducing effect (SMD = -0.27, 95% CI -0.55 to -0.00, P = 0.05). The results also suggest that listening to music may improve patients' quality of sleep following a cardiac procedure or surgery (SMD = 0.91, 95% CI 0.03 to 1.79, P = 0.04).

We found no strong evidence for heart rate variability and depression. Only one study considered hormone levels and quality of life as an outcome variable. A small number of studies pointed to a possible beneficial effect of music on opioid intake after cardiac procedures or surgery, but more research is needed to strengthen this evidence.

Authors' conclusions
This systematic review indicates that listening to music may have a beneficial effect on anxiety in persons with CHD, especially those with a myocardial infarction. Anxiety-reducing effects appear to be greatest when people are given a choice of which music to listen to.

Furthermore, listening to music may have a beneficial effect on systolic blood pressure, heart rate, respiratory rate, quality of sleep and pain in persons with CHD. However, the clinical significance of these findings is unclear. Since many of the studies are at high risk of bias, these findings need to be interpreted with caution. More research is needed into the effects of music interventions offered by a trained music therapist.

Music for stress and anxiety reduction in coronary heart disease patients

Anxiety and pain are common responses to surgery, and both can negatively affect patient outcomes. Music interventions have been suggested as a nonpharmacological intervention to alleviate pain and anxiety during surgical treatment. Although the data are somewhat mixed, the research suggests that music-based interventions are effective in reducing anxiety, pain perception, and sedative intake. The majority of studies have focused on interventions during the postoperative period and address pain reduction, with preoperative use of music targeting anxiety reduction the second most commonly cited objective. Most of the studies found in the literature involve passive music listening via headphones. The data suggest that researcher-selected music is most effective in reducing anxiety, primarily because it incorporates evidence-based parameters such as consistent tempo and dynamics, stable rhythms, and smooth melodic lines. Finally, the literature suggests that music therapists can serve as experts to help medical personnel identify effective implementation strategies.

Using music interventions in perioperative care

Objective: To assess and quantify the effect of perioperative music on
medication requirement, length of stay and costs in adult surgical patients.
Summary Background Data: There is an increasing interest in nonpharmacological interventions to decrease opioid analgesics use, as they have significant
adverse effects and opioid prescription rates have reached epidemic proportions.
Previous studies have reported beneficial outcomes of perioperative music.
Methods: A systematic literature search of 8 databases was performed from
inception date to January 7, 2019. Randomized controlled trials investigating
the effect of perioperative music on medication requirement, length of stay or
costs in adult surgical patients were eligible. Meta-analysis was performed
using random effect models, pooled standardized mean differences (SMD)
were calculated with 95% confidence intervals (CI). This study was registered
with PROSPERO (CRD42018093140) and adhered to the Preferred Reporting
Items for Systematic Reviews and Meta-analysis guidelines.
Results: The literature search yielded 2414 articles, 55 studies (N ¼ 4968
patients) were included. Perioperative music significantly reduced postoperative opioid requirement (pooled SMD 0.31 [95% CI 0.45 to 0.16], P <
0.001, I
2 ¼ 44.3, N ¼ 1398). Perioperative music also significantly reduced
intraoperative propofol (pooled SMD 0.72 [95% CI 1.01 to 0.43], P <
0.00001, I
2 ¼ 61.1, N ¼ 554) and midazolam requirement (pooled SMD 1.07
[95% CI 1.70 to 0.44], P < 0.001, I
2 ¼ 73.1, N ¼ 184), while achieving the
same sedation level. No significant reduction in length of stay (pooled SMD
0.18 [95% CI 0.43 to 0.067], P ¼ 0.15, I
2 ¼ 56.0, N ¼ 600) was observed.
Conclusions: Perioperative music can reduce opioid and sedative medication
requirement, potentially improving patient outcome and reducing medical
costs as higher opioid dosage is associated with an increased risk of adverse
events and chronic opioid abuse.

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The Effect of Perioperative Music on Medication Requirement and Hospital Length of Stay: A Meta-analysis.

Music therapy is a service that has become more prevalent as an adjunct to medical practice-as its evidence base expands and music therapists begin to join the cardiology team in every phase of care, from the most serious cases to those maintaining good heart health. Although applications of music medicine, primarily listening to short segments of music, are capable of stabilizing vital signs and managing symptoms in the short-term, music therapy interventions by a qualified practitioner are showing promise in establishing deeper and more lasting impact. On the basis of mind-body approaches, stress/coping models, the neuromatrix theory of pain, and entrainment, music therapy capitalizes on the ability of music to affect the autonomic nervous system. Although only a limited number of randomized controlled trials pinpoint the efficacy of specific music therapy interventions, qualitative research reveals some profound outcomes in certain individuals. A depth of understanding related to the experience of living with a cardiovascular disease can be gained through music therapy approaches such as nonverbal music psychotherapy and guided imagery and music. The multifaceted nature of musical responsiveness contributes to strong individual variability and must be taken into account in the development of research protocols for future music therapy and music medicine interventions. The extant research provides a foundation for exploring the many potential psychosocial, physiological, and spiritual outcomes of a music therapy service for cardiology patients.

Music therapy in cardiac health care: current issues in research.

A model of the practices that emerge from the interface of music and medicine is presented. Categories include the treatment of medical problems of musicians, music in medical and health education, music for medical patients and staff, and foundational research. Subcategories of these practices are also discussed. These practices are illustrated through a content analysis of the articles published in the first 4 years of Music and Medicine.

A Proposed Model For Identifying Practices: A Content Analysis of the First 4 Years of Music and Medicine

A broadcast music system has evolved at Piedmont Hospital in Atlanta, Georgia, that brings music into the intensive care units (ICUs), operating rooms, periopera- tive areas, gastrointestinal lab, and labor and delivery. A number of years ago, Piedmont Hospital extended its 10- channel music system to the open-heart ICU area, and a pilot study using headphone music was done on a conve- nience sample of 67 patients admitted to this particular ICU area who recovered from coronary artery bypass graft surgery (without valve repair). Patients receiving the treatment (music) spent significantly less time in the ICU (1,357 minutes vs. 1,657 minutes, F 1⁄4 4.29, p 1⁄4 .02). There was a trend for lower sedative charges and ICU charges, but these were not significant. The financial cost of incorporating music in the care of cardiac and cardiac surgery ICU patients is relatively small compared to the potential economic benefits.

A Pilot Study of Patients in Postoperative Cardiac Surgery

The author goes over his many years of experience as an anesthesiologist using music in his practice, and his association with various professionals in music medicine and music therapy.

Fred J. Schwartz

Papers

A Pilot Study of Patients in Postoperative Cardiac Surgery

Music Medicine and Music Therapy and an Anesthesiologist’s Journey Along the Way