Friday, November 2, 2007

Research: Chapter 1: The Effect of Preferred Sedative Music on the Anxiety of Patients During Pacemaker Implant Surgery and Heart Catheterization

Chapter I


During 1997, 518,000 pacemakers were implanted in people around the world. Of those, 147,000 were in the United States (St. Jude Medical, 1998b). A pacemaker is essentially a pulse generator with a lead wire that is attached to the heart muscle. The pacemaker sends electrical impulses to the heart in order to make the heart beat at the appropriate time and rate (St. Jude Medical, 1998c). The Endocardial approach to implanting a pacemaker requires only local anesthesia and leaves the patient alert. In this procedure, the pacemaker is placed in a small pocket under the skin just below the collar bone in the upper chest. The lead wire is threaded through a vein and into the heart (St. Jude Medical, 1998a). It is important for the patient to remain still and relaxed during the implant procedure, so the arms and legs are secured with safety straps and padding to limit movement. Local anesthetic is given at the incision site where the “pocket” is created for the pacemaker. An anesthesiologist monitors the local anesthesia as well as the patient’s vital signs. Other medical staff involved in the procedure are the surgeon, a nurse, a radiology technician who operates the fluoroscopy machine, and a pacemaker industry representative who programs the pacemaker after it has been implanted.

The implant procedure usually lasts about one and one half hours, if there are no complications. The patient may experience increased levels of anxiety and muscle tension due to the prolonged state of restricted movement. In addition, the patient may feel discomfort due to the pre-operative protocols of hair removal from the chest area and restrictions on the intake of food and drink for twenty-four hours prior to the operation. During the procedure, the patient will hear conversations of the medical staff, the sound of the suctioning equipment and x-ray machine, smell the odor of cauterized flesh, and may feel some discomfort depending on the effectiveness of the local anesthesia. According to MacClelland (1979), the sounds of suctioning and conversations of the surgical team can be disturbing and cause stress.

Heart Catheterization

During 1994, 323,000 outpatient cardiac catheterization procedures were performed (American Heart Association, 1998). Cardiac catheterization is a procedure where a doctor inserts a catheter through an artery or vein in the leg or arm and guides this catheter into the heart and coronary arteries much the same way in which the pacemaker lead wire is guided into the heart. The catheter can provide information about the flow of blood through the heart and arteries, and can also serve as a vehicle for injecting diagnostic dyes or balloons to widen the arteries.

Although the end results of catheterization and pacemaker implant are different, the diagnosis and surgical experience for the patients are nearly identical. According to the American Heart Association, cardiovascular disease (CVD) is the umbrella term for high blood pressure and coronary heart disease, which eventually require patients to undergo invasive catheterization or implants (1998).

The heart catheterization procedure places the patient under the same stress inducing conditions and physical environment as in the pacemaker implant procedure. The patient is awake during the procedure and has restricted movement. The same number of personnel are involved and the patient is required to periodically respond verbally to this medical team. The only additional discomfort that heart catheterization patients might feel in comparison with pacemaker implant patients is a burning sensation as dye is injected into the catheter. Though heart catheterization patients do not have to undergo the surgical formation of the “pocket” for the pacemaker, they do have an incision, which is required for catheter insertion.

Patient Anxiety

There is no conclusive evidence that links stress to hypertension or coronary heart disease. Much of the evidence for such an etiological link is anecdotal or observed. Patel (1977, cited in Patel, 1993), has developed a model for the pathogenesis of human hypertension. In this model, he recognizes the natural “fight or flight” response as a basic stress producer that registers in the cerebral cortex as a demand, threat or challenge. This stress influences the cardiovascular components of blood pressure and heart rate. A more recent study conducted by Jiang et al. (1996) determined that patients who exhibited mental stress-induced myocardial ischemia were three times more likely to suffer an adverse cardiac event or to die over a period of up to five years following the stressful incident. Ischemia is the restriction of blood flow within the blood vessels. The 1998 guidelines from The American College of Cardiology and American Heart Association for pacemaker and antiarrhythmia devices indicate that pacemakers can be recommended to solve problems related to hypotension due to peripheral vascular effects, prevention and termination of tachyarrhythmia, and problems resulting from acute myocardial infarction (Cheitlin et al., 1998).

Although pacemaker implant and heart catheterization can be recommended for some problems associated with stress induced symptoms, these same symptoms may cause complications during the implant procedure. Pharmacological intervention for heart rate and blood pressure affected by anxiety is often contraindicated during catheterization and pacemaker implant procedures because of drug interaction issues with the prescription drugs the patient already takes. Controlling the patient’s cardiac parameters through drugs and artificial respiration is also not desirable since the patient should be able to respond to the medical staff verbally throughout the procedure.

The physician, nurse or other medical personnel often communicate with the patient during the operation to assess psychological status, comfort level, and mental awareness. Although a standard sedation is given, all of the patients in this study were still able to verbally respond to these questions. The surgical team seeks to ensure that the patient remains relaxed so that undue muscle tension and anxiety do not adversely affect cardiac parameters. The patient’s heart rate is of particular importance, since heart rate that is too low or too high increases the risks of cardiac failure when the heart’s electric impulses are switched to the pacemaker. This can distress an already weak and diseased cardiovascular system.

Research Question

Patients undergoing heart catheterization or pacemaker implant are placed into environments that may induce anxiety. This anxiety is caused by the sights, sound and feel of the surgical setting. Although the surgeries are implemented to alleviate problems with stress-induced cardiac or circulatory malfunction, the heightened anxiety during surgery may complicate the procedures. The contraindications for sedation of the patient to relieve the elevated anxiety during the surgeries indicate the need for an alternative solution. Therefore, this study examines the effects of preferred, sedative music on the anxiety of patients undergoing heart catheterization and pacemaker implant.


Preferred music for this study was defined as music selected from a choice of three different music styles. The styles of music include: classical, new age and easy listening. The music selections for each group were assigned by the researcher. Music within each group conforms to the definition of sedative music as stated for this study.

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