Music Medicine in Coronary Interventional Cardiology Procedures

Coronary interventional cardiology procedures include invasive percutaneous procedures such as coronary angiography and percutaneous coronary intervention. These procedures are performed in the cardiac catheterization laboratory and may last approximately 30 to 120 minutes, depending on the clinical situation and procedural complexity. Although they are routinely performed and are essential for the diagnosis and treatment of coronary artery disease, the procedural environment, arterial access, manipulation of catheters and guidewires, and uncertainty related to the intervention may be associated with anxiety, discomfort, and pain.

Procedure-related anxiety may have both psychological and physiological consequences. Activation of autonomic and neuroendocrine stress responses may influence cardiovascular parameters and may also increase the perception of procedural pain. Pain itself may have procedural implications. In particular, during transradial procedures, pain and discomfort may contribute to radial artery spasm, which can make catheter manipulation more difficult and, in some cases, require a change to another arterial access site.

Pharmacological strategies, including analgesic and sedative medications, may be used when clinically indicated to manage anxiety, discomfort, and pain during invasive cardiac procedures. However, complementary non-pharmacological approaches may provide additional support without replacing or modifying standard clinical treatment.

Music Medicine refers to the structured use of music within healthcare by trained healthcare professionals according to a defined protocol. In this study, Music Medicine is considered a complementary, patient-centered intervention intended to make the procedural experience more comfortable while preserving all aspects of routine medical and nursing care. Previous research in cardiovascular settings has suggested that music-based interventions may have beneficial effects on psychological distress, anxiety, pain, blood pressure, heart rate, and overall patient well-being. Music has also been studied during angiographic and cardiac catheterization procedures, but evidence concerning a fully personalized music intervention delivered throughout coronary interventional procedures remains limited.

MUSICOR is a prospective, single-center, open-label, randomized controlled study conducted at the Cardiac Catheterization Laboratory of the University Hospital of Sassari, Italy. A total of 208 participants undergoing invasive coronary interventional cardiology procedures will be enrolled and randomly allocated in a 1:1 ratio to either a Music Medicine group or a standard-care group.

Participants will be recruited consecutively during hospitalization. After enrollment and completion of baseline study procedures, participants will be assigned to one of the two study groups using a computer-generated random allocation sequence. The randomization sequence will be prepared by a data manager who is not involved in participant recruitment or clinical management. Allocation will be implemented using sequentially numbered, opaque, sealed envelopes in order to prevent advance knowledge of group assignment. Because participants in the intervention group will listen to music and healthcare professionals must manage the music-delivery system, blinding of participants and clinical staff is not feasible.

### Music Medicine Intervention

Participants assigned to the Music Medicine group will receive a personalized music intervention in addition to routine clinical care.

Before the coronary procedure, a healthcare professional trained in Music Medicine and in the research protocol will discuss the participant's musical preferences. Rather than prescribing a predetermined genre of music, the intervention is centered on the individual participant's preferences. Participants will be encouraged to select music that they personally associate with relaxation, calmness, reassurance, or enjoyment.

The participant may identify individual songs directly or may initially indicate preferred artists, genres, or types of music from which appropriate tracks can then be selected. The final choice of music will remain patient-centered. The participant will also be able to determine the sequence in which the selected tracks are played.

A personalized playlist will then be prepared according to the participant's selections. Before the coronary procedure begins, trained healthcare personnel will verify the audio system, prepare the playlist, and position wireless earphones. Playback will begin before or at the start of the invasive procedure and will continue throughout the procedure according to the predefined sequence selected by the participant.

The audio system is designed so that the use of music does not prevent communication between the participant and the healthcare team. Medical and nursing staff will remain able to communicate with the participant during the procedure through the study communication system whenever clinically necessary. Participants will therefore remain in contact with the clinical team and able to communicate needs or discomfort during the intervention.

The music intervention will not determine or modify any diagnostic, interventional, pharmacological, or therapeutic decision. The arterial access site, procedural technique, use of medications, administration of analgesia or sedation, and any additional treatment will continue to be determined exclusively by the treating physicians according to the participant's clinical condition and routine clinical practice.

The Music Medicine intervention may be discontinued at any time if requested by the participant or if interruption is considered necessary for clinical or procedural reasons. At completion of the coronary procedure, the earphones will be removed and the disposable components of the system will be discarded and replaced before use with another participant.

### Standard-Care Group

Participants assigned to the control group will undergo the coronary procedure according to the routine clinical and nursing care provided in the Cardiac Catheterization Laboratory of the University Hospital of Sassari.

Standard care includes routine preparation for the procedure, continuous clinical monitoring, monitoring of vital signs, medical and nursing assistance throughout the procedure, and administration of pharmacological treatment, including analgesic and/or sedative medication when clinically indicated.

The arterial access site, procedural strategy, interventional techniques, and any additional treatment will be selected according to the participant's clinical condition, physician judgment, and current clinical practice.

Participants in the standard-care group will not wear study earphones and will not listen to either a personalized playlist or other music as part of the study during the coronary procedure. Apart from the Music Medicine intervention, clinical care will be comparable between the two study groups.

### Study Assessments and Data Collection

The study includes a baseline assessment before the coronary procedure and a post-procedure assessment after completion of the intervention.

At baseline, sociodemographic and clinically relevant information will be recorded to characterize the study population. These data include demographic characteristics and selected cardiovascular and clinical variables, such as cardiovascular risk profile, current medical therapy, left ventricular function, body mass index, functional status, and comorbidity burden.

Study assessments will examine psychological, procedural, and physiological aspects of the participant's experience before and after the coronary procedure. The study will also document procedural information relevant to arterial access and any need to change the initially selected access site.

All study data will be entered into a dedicated electronic database using the REDCap platform.

### Patient Experience Component

In addition to the quantitative comparison between the two randomized groups, MUSICOR includes a qualitative component intended to provide a more detailed understanding of how participants experience personalized music during an invasive coronary procedure.

Participants who receive the Music Medicine intervention will be asked about their satisfaction with the intervention. They will also take part in an individual semi-structured interview conducted after the coronary procedure, at a time compatible with their clinical condition.

The interview will be conducted by a psychologist using an open-ended and non-directive approach and will be audio-recorded for subsequent transcription and analysis. Participants will be encouraged to describe the experience in their own words.

The interview will explore several aspects of the intervention, including expectations before the procedure, the meaning attributed to listening to music, perceived emotional and physical effects, the importance of being able to personalize the playlist, comfort and acceptability of the earphones, communication with healthcare professionals while listening to music, perception of the catheterization laboratory environment and passage of time, and any positive, negative, or neutral aspects of the experience.

Participants will also be invited to describe whether they would choose to use personalized music again during a similar future procedure and to provide suggestions regarding music selection, playlist preparation, listening methods, or communication with clinical staff.

The qualitative component is intended to complement the quantitative findings by identifying aspects of acceptability, feasibility, and patient experience that may not be fully captured through standardized measurements.

### Analysis

Quantitative analyses will follow an intention-to-treat approach. Baseline characteristics of the study groups will be summarized using descriptive statistics, and the comparability of the randomized groups will be examined using appropriate statistical tests.

For repeatedly assessed continuous variables, the principal analysis will consider both treatment group and time, as well as the interaction between treatment group and time, in order to determine whether changes occurring across the coronary procedure differ between participants receiving Music Medicine and those receiving standard care. Between-group estimates will be reported with measures of statistical uncertainty and effect size where appropriate. Additional regression analyses may be performed to examine relationships between clinical or demographic characteristics and study variables.

The qualitative interviews will be analyzed using inductive qualitative content analysis. Transcripts will be read repeatedly and relevant meaning units will be identified, condensed, coded, and progressively organized into subcategories and descriptive categories. Where supported by the data, broader themes may also be identified.

The qualitative analysis will primarily focus on the manifest content of participants' accounts while also considering underlying meanings when clearly supported by the interview material. Analytical decisions and changes to the coding structure will be documented to promote transparency and traceability.

The integration of quantitative and qualitative information is intended to provide a more complete understanding of both the measurable effects of personalized Music Medicine and the way in which patients perceive and experience this intervention during coronary interventional cardiology procedures.

MUSICOR is therefore designed not only to determine whether personalized Music Medicine has measurable effects during invasive coronary procedures, but also to assess whether this approach is acceptable and practical within the cardiac catheterization laboratory environment. If the intervention proves beneficial and feasible, it could support the development of a simple, patient-centered complementary strategy that can be incorporated alongside established clinical care without interfering with medical decision-making or procedural management.

Inclusion criteria

• age >18 years;
• provision of written informed consent and ability to understand the informed consent form.

Exclusion criteria

• patients with ST-segment elevation myocardial infarction (STEMI);
• patients with very-high-risk non-ST-segment elevation myocardial infarction (NSTEMI), as classified according to the 2023 European Society of Cardiology (ESC) Guidelines;
• patients in cardiogenic shock;
• presence of hearing impairment or deafness, assessed through clinical history;
• patients unable to express their musical preferences;
• patients with resuscitated cardiac arrest;
• use of antipsychotic medications, assessed through clinical history;
• history of epilepsy, assessed through clinical history.