European Journal of Cardiovascular Medicine

Music has perpetually constituted an indispensable component of the human civilization and an avenue for self-expression for thousands of years. It possesses the extraordinary ability to surpass geographical and cultural boundaries, serving as a universal communication medium, and eliciting an extensive spectrum of sentiments and sensations. Beyond its cultural and aesthetic importance, music also occupies a distinctive position in the realm of medical practice, as an expanding body of scientific investigation underscores its curative capacity in addressing diverse human ailments.

India has one of the oldest unbroken musical tradition in the world as William Butler Yeats(Noble laureate literature -1923) described Indian music as “not an art but life”(1). A country that has musical heritage which shows its use for entertainment as well as healing and rejuvenation may be alone or in combination, to be more specific we can take example of Indian Classical music(ICM).The two existing manifestations of ICM, recognized as North Indian classical music or{ Hindustani Classical Music (NICM) }and South Indian Classical music or Carnatic Classical Music, emerged from a common heritage during the 13th Century AD. Ragas represent a musical entity that evokes sentiments within the psyche, while taal, a rhythmic framework and cycle, constitutes the fundamental essence of ICM.some Indian Ragas such as Raag Bhupali have been documented as having the ability to decrease anxiety by reducing sympathetic activity and enhancing vagal activity. In a similar vein, Raag darbari has been found to have an impact on the cognitive system, thereby augmenting brain efficiency. (2)(3).

The scientific impact of the multitude of ragas found in Indian classical music is still in its nascent stages. The influence of music on our emotions and psychology is profound. When we engage in listening to music, our brains release dopamine, which has the potential to alleviate stress, anxiety, and depression. Various elements of music, including rhythm, melody, harmony, and tempo, play a significant role in stimulating sensorimotor responses, language processing, and cognitive functioning. (4).

It also modifies psycho-physiological parameters such as the perception of pain, relaxation, blood pressure, respiration, and heart rate. The choice of suitable music can establish a soothing and comforting environment, thereby reducing psychological distress in patients. Moreover, music can augment cognitive functions such as memory, attention, and problem-solving abilities. For instance, the "Mozart effect" proposes that listening to classical music can temporarily enhance spatial-temporal reasoning skills. Music therapy has been demonstrated to decrease the perception of pain (5). In the realm of physical rehabilitation, rhythmic music can assist in improving gait and coordination of movement. This proves particularly advantageous for patients who are in the process of recovering from a stroke or traumatic injuries (6). Additionally, certain studies offer initial indications that music therapy may have clinical utility in promoting a sensation of relaxation and increasing activity in the parasympathetic nervous system among cancer patients (7).

The therapeutic potential of music has been acknowledged across different cultures and time periods. Recently, scientific investigations have delved into the physiological and psychological impacts of music. One area of research in this field is the examination of how music affects autonomic nervous system (ANS) activity, plays a vital role in overall health and well-being.

Heart Rate Variability (HRV):Heart Rate Variability pertains to the fluctuation in temporal intervals between successive heartbeats. It fundamentally portrays the extrinsic regulation of heart rate, as well as the adaptability of the cardiovascular system to changing circumstances. Initially expounded upon by Hon & Lee in 1965, they reported on a newborn experiencing fetal distress (8). This measure is non-invasive and is employed to evaluate the functioning of the Autonomic Nervous System (ANS). The ANS constitutes a division of the peripheral nervous system that governs involuntary physiological functions, including heart rate, blood pressure, respiratory rate, and digestion.

 The ANS encompasses two primary divisions: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). These systems function in opposition to maintain homeostasis and respond to diverse stimuli in the surroundings. The Sympathetic Nervous System (SNS) is accountable for the "fight or flight" response, which primes the body for stressful situations by accelerating heart rate, dilating pupils, and redirecting blood flow to the muscles. This response is triggered when the body perceives a threat or danger. Conversely, the Parasympathetic Nervous System (PNS) is responsible for the "rest and digest" response, aiding the body in preserving energy and returning to a state of relaxation. The PNS decelerates heart rate, constricts pupils, and enhances digestion and immune function.

The distinct frequencies of the QRS complex in the ECG (Electrocardiogram) are modulated by the separate rhythmic contributions of sympathetic and parasympathetic autonomic activity. Sympathetic activity, which is associated with the low frequency range (0.04-0.15Hz), and parasympathetic activity, which is associated with the higher frequency range (0.15-0.4Hz), both play a role in modulating the Heart rate (RR) intervals. The ability to analyse HRV (Heart Rate Variability) is made possible by the difference in frequency ranges, allowing for the separation of sympathetic and parasympathetic contributions. This separation is beneficial for early-stage preventive intervention(9)

The most common method of HRV measurement involves the analysis of spectral components, particularly the values of LF (low frequency), HF (high frequency), and the LF:HF ratio. These values provide a reliable representation of the control and balance of the two branches of the autonomic nervous system, specifically for short-term studies. In the context of a 24-hour study, VLF (very low frequency) becomes more significant, along with other statistical parameters such as SDNN [standard deviation ofNN(normal to normal) intervals], SDANN (standard deviation average of NN intervals), RMSSD (root mean squared differences of successive NN intervals), and NN50 (the number of interval differences of successive intervals greater than 50 times). It should be noted that music has been shown to acutely modulate the autonomic system, resulting in noticeable changes. Therefore, most studies have relied on a 5-minute recording of ECG (Electrocardiography)(8-9).

The maintenance of cardiovascular health and overall well-being is contingent upon the delicate equilibrium between the Sympathetic Nervous System (SNS) and the Parasympathetic Nervous System (PNS). A superior state of equilibrium, as evidenced by heightened Heart Rate Variability (HRV), is linked with enhanced capacity for stress adaptation, heightened fortitude, and enhanced cardiovascular performance.

Blood Pressure : Blood pressure (BP) refers to the force exerted by the circulating blood against the walls of blood vessels. The major source of this force is the pumping action of the heart as it propels blood through the circulatory system. In its general usage, the term "blood pressure" specifically denotes the pressure within the brachial artery, which is the most commonly measured location. Blood pressure is typically expressed as the systolic pressure (the highest pressure observed during a single heartbeat) over the diastolic pressure (the lowest pressure occurring between two heartbeats) within the cardiac cycle(8)(9)(11).

Blood pressure is influenced by various factors such as cardiac output, systemic vascular resistance, blood volume, arterial stiffness, as well as the individual's specific circumstances, emotional state, level of physical activity, and overall health condition. In the short term, blood pressure is regulated by baroreceptors, which act through the brain to impact both the nervous and endocrine systems.

A blood pressure that is excessively low is known as hypotension, while consistently elevated blood pressure is referred to as hypertension, and blood pressure within the normal range is called normotension. Both hypertension and hypotension can have numerous causes and may either emerge suddenly or persist for an extended period of time. Prolonged hypertension is a risk factor for various illnesses, including stroke, heart disease, and kidney failure. In fact, long-term hypertension is more prevalent than long-term hypotension(9)(10).

Evidence obtained from electrocardiograms indicates that the presence of left ventricular hypertrophy (LVH) and strain is associated with a higher rate of morbidity and mortality. Heart rate variability (HRV) is significantly reduced in patients with LVH resulting from hypertension or aortic valve disease. The activity of the cardiac vagal nerve is influenced by the arterial baroreflex. The magnitude of respiratory sinus arrhythmia (HRV) has been found to correlate with baroreflex sensitivity, which is diminished in individuals with hypertension and diabetes. This decrease in baroreflex sensitivity is linked to cardiac LVH(7).

INFLUENCE OF MUSIC ON ANS,HRV AND BLOOD PRESSURE

Multiple investigations have been conducted to validate the assertion that music indeed influences the autonomic regulation of the human body, employing Heart Rate Variability (HRV) as a key metric alongside numerous other parameters. Various hypotheses have been proposed to elucidate the underlying mechanism; however, the potential utility of music in treating a wide range of medical conditions is still under active investigation.

Despite the existence of numerous studies investigating the impact of music from various genres on heart rate variability and Blood pressure, limited literature has been found regarding studies conducted on the Indian population, despite the historical evidence of music therapy, known as Raaga Chikitsa.

The findings of the investigation provide substantiation proposing that various regions of the brain are stimulated by ragas, contingent upon the listener's musical knowledge [13]. When individuals partook in passive listening to a specific melodic scale of Indian music, unique cardiovascular effects were witnessed. One scale elicited a mild arousal response, whereas the control group exhibited a relaxation response (14). The implementation of music intervention resulted in noteworthy enhancements in HRV indices, indicating an improved balance of the autonomic nervous system and potential therapeutic benefits for patients with cardiac conditions (15). The positive impact on both the activity of the autonomic nervous system and the regulation of blood pressure was evident (16).The integration of music into integrated yoga had a positive influence on HRV and emotional well-being (17). Specific interventions that encompass Indian classical music influenced HRV parameters, supporting its potential as a technique for inducing relaxation (18).

The effect of music was observed to induce a state of calmness, as evidenced by an increase in parasympathetic activity and an improvement in HRV (19).

The act of listening to music in one's native language has the ability to enhance para sympathetic activity, while unfamiliar music has the potential to increase sympathetic drive (20).The genre or type of music has no discernible impact on anaerobic exercise, thus rendering it an insignificant factor in optimizing performance (21).To enhance emotional well-being, personalized music recommendations can be provided to individuals based on their brain activity (22).Engaging in music making and listening on a regular basis may have long-lasting effects on autonomic tone, which refers to the balance between sympathetic and parasympathetic activity (23).Rabindra sangeet, a form of music, has a positive effect on human physiology. Playing a musical instrument has the ability to mitigate the stress response and improve both physical and emotional health(24).

Passive engagement in Hindustani melodic scale music was observed to yield an elevation in diastolic blood pressure and a marginal increase in systolic blood pressure (25). In a comparative study conducted by RohitLoomba et al(26) those who did not undergo music therapy were compared to those who did receive music therapy. It was found that the latter group experienced a significantly greater reduction in SBP prior and subsequent to the intervention (mean difference, −2.629, confidence interval (CI), −3.914 to −1.344, P < 0.001). Moreover, a significantly greater decrease in DBP (mean difference, −1.112, CI, −1.692 to −0.532, P < 0.001) and HR (mean difference, −3.422, CI, −5.032 to −1.812, P < 0.001) was observed. In a study conducted by Kirthana et al(27), the 24-hour ambulatory blood pressure of 50 subjects was examined. It was found that the combination of music intervention with lifestyle modification led to a decrease in diastolic blood pressure, especially in individuals with initial blood pressure in the pre-hypertension range. FPKow et al(28) compared a control group to an intervention group that received music-guided deep breathing exercises. The results showed a significant decrease in systolic and diastolic blood pressure from baseline after 8 weeks. The control group exhibited a mean reduction of 10.5mmHg in systolic blood pressure and 5.2mmHg in diastolic blood pressure, while the intervention group experienced a mean decrease of 8.3mmHg in systolic blood pressure and 5.6mmHg in diastolic blood pressure. Although the difference between the two groups was statistically non-significant, the absolute difference from baseline was 2.2mmHg in systolic blood pressure and 0.4mmHg in diastolic blood pressure. These findings suggest that listening to music combined with deep breathing exercises is associated with a clinically significant decrease in systolic and diastolic blood pressure.

JenniferRWalton et al(29) conducted an analysis and discovered that listening to music may have a positive impact on obtaining more accurate systolic blood pressure readings in children with Williams syndrome. When blood pressure was measured at two different time points, there was a decrease in systolic blood pressure by 3.8 mmHg in the music group compared to the non-music group. Niken et al(30) found that older adults with hypertension experienced better control of their blood pressure through progressive muscle relaxation and music therapy. This therapy was administered in 11 sessions, six days a week. The paired t-test showed a decrease in systolic blood pressure to 29.2 mmHg and diastolic blood pressure to 16.2 mmHg. XFTeng et al(31) conducted a study involving 30 subjects (aged 63-93 years) diagnosed with hypertension. They were divided into a music group (n=15) and a control group (n=15). The participants in the music group listened to music as a therapy for 25 minutes, four days a week. Blood pressure was measured before and after four weeks of therapy. The study found that certain types of music may decrease systolic blood pressure, and this effect could last up to four weeks.

Mayra et al(32) conducted a meta-analysis to examine the effect of music on systolic blood pressure and diastolic blood pressure in hypertensive patients. When the weighted mean difference was compared with the control group, no significant difference was found for diastolic blood pressure. However, systolic blood pressure and heart rate were significantly reduced, suggesting that music can be considered as a component of care for hypertensive patients. ImtiyazAliMir et al(33) selected pre-hypertensive young adults (systolic blood pressure 120-139 mmHg, diastolic blood pressure 80-89 mmHg) and divided them into two groups: a control group (with dietary modification and sodium restriction) and a music group (with music therapy along with dietary modification and salt restriction). While there were no significant changes in the control group, the music group experienced a decrease in systolic blood pressure by 8.73 mmHg and a reduction in heart rate by 6.42 beats per minute. Although the change in diastolic blood pressure was not as significant, it still proves to be a promising tool in preventing the progression of pre-hypertension among young adults.

Listening to music possesses the potential to positively impact the state of consciousness in patients who are in a vegetative condition(34). The incorporation of Indian classical music, specifically Ragga Bhupali, can prove advantageous for individuals with cardiovascular disorders due to its ability to reduce sympathetic activity and enhance vagal modulation.

Music that possesses sedative qualities has the effect of diminishing the activation of the parasympathetic nervous system, while heavy metal music exerts a more substantial influence on the sympathetic component. The utilization of music therapy involving raga music has demonstrated the ability to augment the well-being of individuals afflicted with diabetes, low blood pressure, high blood pressure, and chronic stress(35).

Engaging in the listening of specific Indian music scales has been discovered to have an impact on cardiovascular parameters. Research investigations focused on evidence-based music therapy have yielded promising outcomes in relation to psychiatric conditions(4). Furthermore, the utilization of instrumental Indian classical music has been found to significantly diminish anxiety, depression, and stress levels in male medical students. Additionally, it has been observed to reduce salivary cortisol levels, blood pressure, heart rate, and fasting blood sugar levels(4).

In conclusion, the reviewed studies collectively shed light on the potential advantages of music interventions on heart rate variability (HRV) and the autonomic nervous system (ANS) among diverse populations. These findings underscore the potential of music as a complementary therapeutic tool for promoting autonomic equilibrium, enhancing cardiovascular health, and improving overall wellness. Unfortunately, it is crucial not to overlook the limitations of these studies. Firstly, the studies were conducted on small groups, further narrowed down by specific disease entities under investigation. Therefore, it would be an overestimation to generalize these results to a larger apparently healthy population. Consequently, there is a need for a meta-analysis of these studies to draw any conclusive findings and cater to the needs of patients. Secondly, music encompasses multiple components such as frequency, tone, rhythm, beat, loudness, lyrics, aesthetics, and the concept of familiarity and unfamiliarity. To examine its effects on various bodily functions, a multidisciplinary approach is likely required. This may involve the development of a subject music data-based interface that can automatically cater to the individual needs of the world's population of 7.7 billion, while also adapting to the FITT (frequency, intensity, timing, type) principle, which would be valuable in evaluating and prescribing music for both observational and interventional studies (36). Although Western classical music has been extensively studied, there is still a need for systematic research on traditional music from different cultures to determine their unique therapeutic value. Furthermore, the introduction of technology, such as data mining, in music therapy can enhance its efficiency, feasibility, and implementation at any level (36-37).

According to the World Health Organization (WHO) Cardiovascular diseases (CVD) are a leading cause of mortality worldwide representing 32% of global deaths, 85% due to Heart attack and stroke.(10), Additionally, individuals who have pre-hypertension (with systolic blood pressure ranging from 120 to 139 mm Hg and diastolic blood pressure ranging from 80 to 89 mm Hg) face an elevated likelihood of developing hypertension and experiencing a rise in the occurrence of cardiovascular morbidity, particularly among young adults aged 18 to 30 years or older. A slight reduction in blood pressure may result in a decrease in the prevalence of morbidity and mortality. It has been observed in specific studies that the long-term use of anti-hypertensive medications such as β blockers and angiotensin 2 receptor blockers (ARBs) can increase the overall risk of stroke to at least 56%. Although these studies only focused on a few hypertensive drugs and were observational in nature, the potential escalation in the risk of cardiovascular morbidity and mortality cannot be disregarded(38,39,40).

hence, there is an amplified rationale to explore the possibility of incorporating music as a preventive therapy in conjunction with established treatment protocols, with the objective of diminishing the linked morbidity and mortality rates and striving for a more robust populace. Nevertheless, it is imperative to invest efforts in comprehending its scientific foundations and conducting more large-scale research, as well as promoting the positive effects of music across the population through collaborative endeavour to attain a superior state of well-being.

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