- Email: [email protected]
Efficacy of complementary interventions for management of anxiety in patients undergoing coronary angiography: A rapid systematic review
Vol. - No. -
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
PAGE 1
Efficacy of complementary interventions for management of anxiety in patients undergoing coronary angiography: A rapid systematic review Mina Bordbar, MScN, Zhila Fereidouni, PhD, Morteza Kameli Morandini, MSN, and Majid Najafi Kalyani, PhD
Coronary angiography (CAG) is an invasive and anxiety-provoking procedure for many patients. Psychological problems, especially anxiety, are the main concern of nurses taking care of these patients before the procedure. This rapid systematic review aimed to assess the efficacy of interventions for management of anxiety in patients undergoing CAG. In this study, all published, peer-reviewed, English-language interventional studies from 2009 to 2018 were identified in a search of Scopus, PubMed, and Google Scholar databases. The relevant studies were assessed using a quality assessment checklist. All included studies were assessed by 2 researchers. Finally, 15 studies with 1,312 participants that evaluated the effects of complementary methods on management of anxiety in patients undergoing CAG were included. The findings of this rapid systematic review suggested that complementary and nonpharmacological methods, such as music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga, could be used effectively for management of anxiety in patients undergoing CAG. (J Vasc Nurs 2019;-:1-9)
INTRODUCTION Cardiovascular disease (CVD) is the most common cause of mortality worldwide.1 Among CVDs, which include a wide range of diseases, coronary artery disease (CAD) is the most common and the most prominent cause of deaths resulting from CVDs.2 Different invasive and noninvasive methods are used to diagnose CAD.3,4 One of the most common and accurate diagnostic tests for this disease is coronary angiography (CAG), which shows the extent and severity of coronary artery stenosis.3,4 Because of its high accuracy, CAG is known as the golden test and standard diagnosis of CAD.3–5 Despite its various advantages in making an accurate diagnosis, CAG causes psychological problems due to its invasive nature.5 One of the most common psychological problems in patients undergoing this procedure is anxiety.6,7 Studies have shown high anxiety From the Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran; Assistant Professor, School of Nursing, Fasa University of Medical Sciences, Fasa, Iran; Faculty of Medicine, Department of Nursing, Sari Branch, Islamic Azad University, Sari, Iran; Associate Professor, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran. Corresponding author: Majid Najafi Kalyani, PhD, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran (E-mail: [email protected]).
levels in these patients.4,7 The waiting time, fear of death, lack of knowledge, and results of angiography have been listed as the main causes of anxiety in these patients.4,5 High levels of anxiety in patients undergoing CAG increase the secretion of catecholamines and enhance the burden of cardiovascular and chest pain, which can endanger the patients’ well-being in the catheterization laboratory.3,5 To manage anxiety in patients undergoing CAG, pharmacological and nonpharmacological methods have been used.8 Nonpharmacological methods include a range of interventions that are more widely used due to lower cost, fewer complications, and ease of implementation in clinic setting.9,10 One of the nonpharmacological methods that has been more promising in the recent years is the use of complementary therapies as part of or on the side of nursing interventions for management of anxiety in these patients. Several studies have been undertaken on the impact of complementary methods such as music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga on anxiety management among patients under CAG.10–24 Considering the different results about the most effective methods in reducing anxiety among these patients and the importance of anxiety control in patients undergoing CAG, using of complementary therapies as a safe, low-cost, and easy method to manage this problem seems necessary. This study aims to investigate the studies carried out on the use of complementary therapies for anxiety control in patients undergoing CAG.
METHODS 1062-0303/$36.00 Ó 2019 Society for Vascular Nursing. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvn.2019.12.005
Study design This rapid systematic review aimed at summarizing the best available evidence related to the efficacy of complementary therapies in managing anxiety in patients undergoing CAG.
PAGE 2
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
- 2020
Search strategy
Data extraction
Scopus, PubMed, and Google Scholar databases were searched using keywords such as coronary angiography, anxiety, nonpharmacological interventions, nursing interventions, and complementary therapies during 2009–2018. To achieve these studies, all published English-language articles were examined separately and in combination with each other to find the relevant studies. The searched studies were imported into EndNote X8 (Clarivate Analytics) for assessment and management.
The initial search revealed 138 studies. These were reviewed for eligibility by 2 researchers in terms of relevancy and quality. Eventually, 15 studies were included in the rapid systematic review. The quality of the studies was examined based on the critical appraisal checklist for articles. In this study, the checklist presented by Downs and Black25 was used for critical appraisal of the studies. The final studies were reviewed by 2 researchers. Then, the name of the author, year of the study, country, sample size, study design, type of intervention, anxiety measuring instrument, and the overall study result were extracted using a standard form.
Selection of studies The main criterion for inclusion of studies into this rapid systematic review was the application of complementary therapies and nursing interventions for anxiety management in patients undergoing CAG. The inclusion criteria of this study were possessing an interventional design, having a control group, reporting anxiety score in patients as a mean value, carrying out interventions based on one or more practices of complementary therapies, and using an appropriate instrument for measuring anxiety in angiography patients. The exclusion criteria were lack of the mean anxiety score, being a single group study, lack of a control group, using pharmacological methods to treat anxiety in patients, and lack of an appropriate quality. It should be noted that the studies covering the period from 2009 to 2018 were included in the study, while those conducted before 2009 were excluded. After studying the full texts of the articles by 2 researchers, based on the inclusion and exclusion criteria, appropriate articles were included in the study as shown in Figure 1. All selected articles were discussed by 2 researchers, and then the final articles were included by the agreement between these researchers.
Eligibility criteria In this study, 4 main eligibility criteria, that is, Population (P), Intervention (I), Comparison (C), and Outcome (O), were used to review the studies as follows: P: all patients undergoing CAG, I: complementary therapies used to manage anxiety, C: routine care versus complementary therapies, and O: anxiety score as the only studied outcome in patients.
Figure 1. Flow diagram of the studies selection.
RESULTS
Characteristics of the studies From 138 studies in the initial search, 15 studies were maintained. These 15 studies were conducted on 1,312 participants. The features and findings of the studies included in this rapid systematic review have been presented in Table 1. Considering the type of intervention used to manage anxiety in patients undergoing CAG, these studies were categorized into 6 groups, including music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga. The clinical trial method was used in the methodology of all studies (100%). In addition, patients’ anxiety level was the main outcome of these studies, which was evaluated through various tools. The most commonly used tool in the majority of studies (78%) was Spielberger’s State-Trait Anxiety Inventory (STAI).11–21,24 This tool consisted of 40 expressions to determine 2 domains of overt (20 questions) and covert (20 questions) anxiety. The questions of this tool were measured from 1 to 4 based on Likert 4-degree scale. The total scores of both covert and overt anxiety scale were in the range of 20–80.21 Other used tools (22%) for measuring anxiety were Beck Anxiety Inventory;10 Hamilton Anxiety Rating Scale;22 and Depression, Anxiety, Stress Scale.23
Vol. - No. -
TABLE 1 CHARACTERISTICS OF THE REVIEWED STUDIES
Year
Country
Design
Participants
Intervention
Moazami Goudarzi et al10
2018
Iran
RCT
Total: 60 Intervention group: 30 Control group: 30
Iran
RCT
Total: 150 Intervention: 50 Control: 50 Placebo: 50
2017
Iran
RCT
Total: 80 Intervention: 40 Control: 40
Ziyaeifard et al13
2017
Iran
RCT
Total: 80 Intervention: 40 Control: 40
Rejeh et al14
2016
Iran
RCT
Total: 130 Intervention: 65 Control: 65
Benson’s relaxation technique was performed for 15– 20 minutes. The patient lay on the bed and an audio file containing relaxing words was played. Reflexology was provided through compressing and stimulating the solar plexus, heart, and pituitary reflex points at the plantar surface of the participants’ feet for 20 minutes. Massage with thumb and with the left hand and then moved to the right hand, started from the forearm moving to the wrist, palm, back of the hand, and finally the fingers. The massage was repeated 8 to 10 times. The patients smelled a piece of cotton wool soaked in 5 drops of lavender essential oil at a distance of 5 cm from the nose with deep inhalations for 5 minutes. Patients were asked to listen to pleasant natural sounds.
Ramezanibadr et al11
2018
Mobini-Bidgoli et al12
Outcome Measure and Tool
Findings Significant difference between the patients’ anxiety levels before and after the intervention (P < .05).
SAI
The level of state anxiety was significantly lower in the intervention group compared to the placebo and control groups (P < .05).
SAI
The mean anxiety level decreased in the intervention group after the intervention (P = .0001).
SAI
The level of anxiety decreased significantly in the intervention group in comparison to the control group (P < .05).
SAI
The intervention group displayed significantly lower anxiety levels compared to the control group during the intervention (P = .001). (Continued)
PAGE 3
BAI
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
Author
PAGE 4
TABLE 1 CONTINUED
Author
Country
Design
Participants
Tahmasbi and Hasani15
2016
Iran
RCT
Total: 70 Intervention: 35 Control: 35
Mobini Bidgoli et al16
2016
Iran
RCT
Total: 80 Intervention: 40 Control: 40
Pourmovahed et al17
2016
Iran
RCT
Foji et al18
2015
Iran
RCT
Total: 70 Intervention: 35 Control: 35 Total: 62 Intervention: 31 Control: 31
Mahmoudirad et al19
2014
Iran
RCT
Total: 70 Intervention: 35 Control: 35
Molavi Vardanjani et al20
2013
Iran
RCT
Total: 100 Intervention: 50 Control: 50
Intervention
Outcome Measure and Tool
Findings
SAI
Use of Benson’s relaxation technique significantly decreased the anxiety level in the intervention group (P = .0001).
SAI
The mean anxiety score significantly decreased in the intervention group after the intervention (P = .0001).
SAI
The intervention protocol included 30 minutes of general foot massage and stimulation of 3 reflex points, including solar plexus, pituitary gland, and the heart.
SAI
A significant difference was observed between the groups after the intervention (P = .008). The level of anxiety decreased significantly in the guided imagery group after the intervention (P < .05). There was a significant difference between the 2 groups’ anxiety mean scores after the intervention (P < .001). The mean range of anxiety decreased in the reflexology group (P = .0001).
SAI
SAI
- 2020
An audio file with recorded instructions on Benson’s relaxation exercises was prepared. The exercises were performed by the patients in the presence of the researcher 1 day before angiography. This state was maintained for 20 minutes. Patients performed sukha pranayama exercises. They were trained to breathe slowly and rhythmically at a rate of 10 breathings per minute for 5 consecutive minutes. The intervention group listened to music for 20 minutes 1 hour before angiography. The intervention group participants were asked to listen to a guided imagery CD for 18 minutes. Patients received foot reflexology for 20 minutes.
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
Year
Iran
RCT
Total: 91 Intervention: 45 Control: 46
Mei et al22
2012
China
RCT
Tota: 100 Intervention: 50 Control: 50
Moradipanah et al23
2009
Iran
RCT
Total: 74 Intervention: 37 Control: 37
Heidari et al24
2017
Iran
RCT
Total: 90 Intervention: 45 Placebo: 45
In the intervention group, 2 drops of Lavendula were dropped on cotton balls in a pot with the volume of 10 mL using a dropper. The patients were required to keep it at a distance of 5 cm from their noses and to sniff for 3 minutes. The intervention group received Chinese hand massage care in conjunction with the same conventional therapies and care as the control group. The intervention group was given a tape player and a music cassette. The 20-minute tape consisted of 3 pieces of relaxing music. Hand reflexology was performed in the intervention group 20 minutes prior to coronary angiography.
SAI
The anxiety level decreased significantly in the intervention group compared to the control group after aromatherapy (P < .0001).
Hamilton anxiety rating scale
The anxiety scores significantly decreased in the intervention group (P < .01).
DASS-21
There was a significant decrease in the mean score of state anxiety in the intervention group (P = .006).
SAI
In the intervention group, the mean level of state anxiety decreased from 49.82 1.74 at baseline to 42.67 1.47 after the intervention (P = .0001).
BAI = Beck Anxiety Inventory; CD = compact disc; DASS-21 = Depression, Anxiety, Stress Scale; RCT = randomized clinical trial; SAI = Spielberger’s State-Trait Anxiety Inventory.
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
2012
Vol. - No. -
Tahmasbi et al21
PAGE 5
PAGE 6
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
- 2020
Music therapy
Benson’s relaxation technique
Three studies were conducted to examine the effect of music therapy on controlling the anxiety of patients undergoing CAG. All these studies showed that music caused a general reduction in the anxiety of patients undergoing CAG. The study conducted by Rejeh et al14 on 130 patients in control and intervention groups showed that hearing music (pleasant natural sound) before angiography for 20 minutes significantly decreased the intervention group’s anxiety score (by STAI) compared with that of the control group (anxiety score differences = 16). In another study, Moradipanah et al23 randomly divided 74 patients into control and intervention groups. In that study, a relaxing music with slow and steady rhythm was played for the intervention group for 20 minutes. The results showed that listening to music decreased the intervention group’s mean score of anxiety from 6.83 4.14 to 2.83 3.55.23 Pourmovahed et al17 also conducted a clinical trial on 70 candidates for CAG. They randomly divided the patients in control and intervention groups. Patients in the intervention group listened to a relaxing music (sound of nature) for 20 minutes before undergoing CAG. The results showed that listening to music significantly changed the intervention group’s anxiety score from 48.45 6.63 (before the intervention) to 44.28 5.21 (after the intervention).17 The aforementioned studies indicated the positive effects of music on reduction of anxiety in patients undergoing CAG.
Two studies with 130 participants were conducted on the effect of Benson’s relaxation technique (relaxation exercises) on controlling the anxiety of patients undergoing CAG. Moazami Goudarzi et al10 performed Benson’s relaxation technique by simultaneous voice training before coronary angiography for the intervention group patients for 15–20 minutes. The results indicated a significant improvement between the patients’ anxiety scores before and after the intervention.11 In a study conducted by Tahmasbi and Hasani,15 70 patients were randomly divided into control and intervention groups. Patients in the intervention group received the audio file (with headphones) of Benson’s relaxation technique (recorded instructions on relaxation exercises) before coronary angiography for 20 minutes. The results showed that Benson’s relaxation technique significantly decreased anxiety among the patients in the intervention group.15
Reflexology There were 6 studies that assessed the effect of reflexology on anxiety in 590 patients. In a study conducted by Mei et al22 in China, 100 patients were randomly divided into control and intervention groups. Hand massage using Chinese method consisted of 3 sequent points (Fengchi [EX-HN5], Shenmen [GB20], Taiyang [HT7]). It was done 15 minutes a day for 3 days before coronary angiography on the patients in the intervention group. Based on the results, Chinese massage significantly decreased the anxiety score.22 In a study conducted by Molavi Vardanjani et al,20 foot massage by stimulation of 3 reflexology area for 30 minutes 1 day before angiography caused a significant decrease in the anxiety score of 50 patients included in the intervention group. Mobini Bidgoli et al12 assessed the effect of hand reflexology through the 6 reflexology points on anxiety level of 80 patients undergoing CAG. In that study, the patients’ anxiety level was measured through STAI (STAI). The results showed that hand reflexology led to a significant decrease in the intervention group’s anxiety score after the intervention (55.47) compared with that at the baseline (57.54).12 Mahmoudirad et al19 reported that foot reflexology through foot’s solar grid point for 20 minutes caused a significant decrease in the experimental group’s mean score of anxiety compared with that of the control group. Ramezanibadr et al11 also investigated the effect of foot reflexology through compressing and stimulating the solar plexus, heart, and pituitary reflex points on 150 male patients undergoing CAG. In that study, foot reflexology significantly decreased the anxiety scores of patients in the intervention group compared with those of the control and placebo groups.11 Similarly, Heidari et al24 found that applying general hand massage was associated with a decrease in the patients’ anxiety mean scores.
Aromatherapy Two studies were conducted to investigate the effect of aromatherapy on controlling the anxiety of patients undergoing CAG. Tahmasbi et al21 used 10 cc of Lavendula extract (aromatic agent) for the intervention group patients for 3 minutes. After analyzing the patients’ anxiety levels by STAI, the results showed a significant decrease in the intervention group patients’ anxiety levels compared with before the intervention.21 The other study was conducted by Ziyaeifard et al,13 which showed that smelling 5 drops of lavender oil (a strong aromatic agent) at a distance of 5 cm from the nose for 5 minutes decreased anxiety levels (assessed by STAI) among patients undergoing CAG.
Guided imagery A study with 62 participants was conducted to investigate the effect of guided imagery on controlling the anxiety of patients undergoing CAG. Foji et al18 demonstrated that using a compact disc of guided imagery (approved by researchers and ethics committee) for 18 minutes through headphones decreased the anxiety score from 103.67 13.9 (before the intervention) to 89.25 11.03 (after the intervention). In this study, the patients were put in a quit environment while listening to audio crating a guided mental image, and their anxiety was assessed by STAI. Thus, the researchers approved that guided imagery could be used as an effective method to decrease anxiety levels among patients undergoing CAG.18
Yoga Mobini Bidgoli et al16 conducted a study to investigate the effect of sukha pranayama technique as one of the yoga methods on controlling the anxiety of patients undergoing CAG. In that study, 80 patients were randomly divided into control and intervention groups. In the intervention group, the patients performed sukha pranayama breathing exercises rhythmically and slowly for 5 minutes. The results revealed that the patients’ anxiety scores (assessed by STAI) decreased from 53.37 (before the intervention) to 40.75 (after the intervention).16 Hence, this easy and noninvasive technique was recommended to be used for controlling patients’ anxiety.
Vol. - No. -
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
DISCUSSION This rapid systematic review study showed that application of complementary therapies might help reduce anxiety in patients undergoing CAG. A review on 3 studies indicated that application of music therapy ended up reducing the level of anxiety among these patients.14,17,23 According to these studies, listening to music for 20 minutes before CAG was reportedly effective in reducing the patients’ anxiety scores.14,17,23 As patients often experience high levels of anxiety before CAG,3–7 it seems appropriate to use nonpharmaceutical interventions, such as music therapy.26 Effectiveness of music therapy in reducing the level of anxiety among patients during normal care was proven in a systematic review study performed by Evan et al.27 However, given the wide range of music therapy methods and music types, it is necessary to undertake further research on this issue. Reflexology has been introduced as an effective approach to anxiety reduction among patients undergoing CAG according to 6 studies including 590 participants. These 6 studies examined different methods of foot massage, hand massage, and Chinese massage.11,12,19,20,22,24 For example, Ramezanibadr et al11 performed foot massage for 20 minutes, while Molavi-Vardanjani et al20 examined 30-minute foot massage together with stimulation of different reflex points. Despite the effectiveness of this method in reducing the patients’ anxiety levels, the literature has proposed no single universal method for achieving this goal. According to the results of the research performed so far, a possible cause of this effectiveness is the enhanced activity of parasympathetic neural system and reduced activity of the sympathetic neural system in decreasing the levels of anxiety.28,29 While performing this method, it is recommended to pay adequate attention to differences in actual practice of the interventions, duration of the intervention, patient’s waiting time before CAG, and personal differences among different patients. Studies conducted on a total of 130 patients undergoing CAG revealed that application of Benson’s relaxation technique ended up reducing their anxiety scores. In a study performed by Tahmasbi and Hasani,15 a 20-minute relaxation technique succeeded to reduce the patients’ anxiety levels. Moazami Goudarzi et al10 also performed a study and reported the effectiveness of a 15- to 20-minute relaxation procedure in lowering the anxiety scores. In the same vein, the results of the study performed by SadeghiMoghadam et al30 on patients engaged with CAD and the one performed by Georgianni et al31 on hemodialysis patients showed that application of Benson’s relaxation technique reduced the patients’ anxiety levels. Given the limited number of studies carried out on the effectiveness of this method in lowering the level of anxiety among patients undergoing CAG, one should pay attention to factors such as the intervention duration and the best protocol to apply the intervention. Easy application, low cost, and nonpharmaceutical nature of this method as an effective nursing intervention highlight the necessity of further research in this area. Aromatherapy has been introduced as an easy, nonpharmaceutical method for controlling patients’ anxiety levels. The findings of 2 studies performed by Ziayifard et al13 and Tahmasbi et al21 showed that the patients experienced lower levels of anxiety in case of breathing aromatic substances before CAG.
PAGE 7
Application of aromatherapy was also reportedly effective in reducing the problems experienced by other patients. According to Ezgi Karadag et al,32 application of aromatherapy ended up reducing the level of anxiety while enhancing the sleep quality among the patients hospitalized in intensive care units. In another research, Mi-Yeon Cho et al33 indicated that aromatherapy was associated with reduced anxiety and enhanced sleep quality among the patients subjected to coronary angioplasty. Moreover, Shiina et al34 emphasized the impact of aromatherapy on improvement of coronary artery blood circulation. Considering the increase in the anxiety level among patients undergoing CAG and the significant impact of anxiety on the patients’ physical and mental performances, this nonpharmacological and lowcost method is recommended to be applied for taking care of such patients. However, given the limitations of the existing literature on the impact of aromatherapy on patients’ anxiety levels, further research on the issue is warranted. Few studies found in this research were those related to the impacts of guided imagery and yoga on anxiety control among patients undergoing CAG. The study performed by Foji et al18 showed that application of guided imagery was associated with lower anxiety scores. Evidence has emphasized the use of this technique as a low-risk, safe, and nonpharmacological approach for patients.35–37 Given the need for patients’ collaboration and participation when it comes to the application of this method, one may pay attention to this need to enhance the efficiency of this care method.18 Furthermore, a study with 80 participants confirmed the effectiveness of yoga in anxiety reduction. In that study, Mobini Bidgoli et al16 used sukha pranayama exercises and found that rhythmic and low-pace performance of these exercises resulted in a significant decline in anxiety scores among the patients undergoing CAG. The positive effect of this method on lowering anxiety levels among patients suffering from back pain was also reported in a study by Tekur et al.38 It was effective in lowering anxiety levels among pregnant women, as well.39 Considering the variety of yoga exercises, one should pay attention to such considerations as the duration of exercises, patient’s background conditions, and time of practicing the exercises. Indeed, nurses and other medical staff have to be trained regarding this method and its application for patients. Yet, further research is required to be conducted on the issue. A strong point of this study was the inclusion and investigation of all studies performed on the effects of complementary therapies among patients undergoing CAG. Although the quality of the studies was considered herein, the present research suffered from limitations such as differences in the sample size as well as limited geographical locations where the studies were performed. Another study limitation was that different researchers had followed various approaches to the application of the same intervention.
CONCLUSION This rapid systematic review revealed that complementary therapies, such as music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga, could be used as effective interventions separately or in conjunction with nursing interventions for reducing the level of anxiety among the patients undergoing CAG. Although the wide variety
PAGE 8
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
of the studies performed so far makes it difficult to draw any accurate conclusion, the findings indicated preliminarily that the use of complementary therapies was effective in reducing the level of anxiety among the patients undergoing CAG. Yet, application of these methods for taking care of patients undergoing CAG requires further researches to determine definitive methods.
11.
AUTHORS’ CONTRIBUTION
12.
M.B., Z.F., M.K.M., and M.N.K. developed the study design and conception, searched for and extracted the data, and wrote and finally approved the manuscript.
13.
DISCLOSURE None declared.
14.
ACKNOWLEDGMENTS This article was extracted from a Master’s thesis written by M.B. and was supported by Fasa University of Medical Sciences. The authors would like to thank Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript.
15.
16.
REFERENCES 1. Loucks EB, Lynch JW, Pilote L, et al. Life-course socioeconomic position and incidence of coronary heart disease: the Framingham Offspring Study. Am J Epidemiol 2009; 169(7):829-36. 2. Woods SL, Froelicher ES, Motzer SA, et al. Cardiac nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. 3. Kalyani MN, Sharif F, Ahmadi F, et al. Iranian patient’s expectations about coronary angiography: a qualitative study. Iran J Nurs Midwifery Res 2013;18(3):180. 4. Molazem Z, Shahabfard Z, Askari A, et al. Effects of a peerled group education on fear, anxiety and depression levels of patients undergoing coronary angiography. Invest Educ Enferm 2018;36(1):e13. 5. Sharif F, Kalyani MN, Ahmadi F, et al. In the shadow of perceived threat: the live experience of Iranian patients candidate for undergoing coronary angiography. J Vasc Nurs 2018;36(3):140-4. 6. Lunden MH, Bengtson A, Lundgren SM. Hours during and after coronary intervention and angiography. Clin Nurs Res 2006;15(4):274-89. 7. Uzun S, Vural H, Uzun M, et al. State and trait anxiety levels before coronary angiography. J Clin Nurs 2008;17(5):602-7. 8. Carroll DL, Malecki-Ketchell A, Astin F. Non-pharmacological interventions to reduce psychological distress in patients undergoing diagnostic cardiac catheterization: a rapid review. Eur J Cardiovasc Nurs 2017;16(2):92-103. 9. Williams A, Ishimine P. Non-pharmacologic management of pain and anxiety in the pediatric patient. Curr Emerg Hosp Med Rep 2016;4(1):26-31. 10. Goudarzi YM, Ghadirian F, Vahedian A, et al. The effect of benson relaxation on the anxiety of patients under radial
17.
18.
19.
20.
21.
22.
23.
24.
- 2020
angiography: a randomized clinical trial. Crit Care Nurs 2018;11(1):e65623. Ramezanibadr F, Amini K, Hossaingholipor K, et al. The impacts of foot reflexology on anxiety among male candidates for coronary angiography: a three-group single-blind randomized clinical trial. Complement Ther Clin Pract 2018; 32:200-4. Mobini-Bidgoli M, Taghadosi M, Gilasi H, et al. The effect of hand reflexology on anxiety in patients undergoing coronary angiography: a single-blind randomized controlled trial. Complement Ther Clin Pract 2017;27:31-6. Ziyaeifard M, Zahedmehr A, Ferasatkish R, et al. Effects of lavender oil inhalation on anxiety and pain in patients undergoing coronary angiography. Iran Heart J 2017; 18(1):44-50. Rejeh N, Heravi-Karimooi M, Tadrisi SD, et al. The impact of listening to pleasant natural sounds on anxiety and physiologic parameters in patients undergoing coronary angiography: a pragmatic quasi-randomized-controlled trial. Complement Ther Clin Pract 2016;25:42-51. Tahmasbi H, Hasani S. Effect of Benson’s relaxation technique on the anxiety of patients undergoing coronary angiography: a randomized control trial. J Nurs Midwifery Sci 2016;3(1):8-14. Bidgoli MM, Taghadosi M, Gilasi H, et al. The effect of sukha pranayama on anxiety in patients undergoing coronary angiography: a single-blind randomized controlled trial. J Cardiovasc Thorac Res 2016;8(4):170. Pourmovahed Z, Tavangar H, Mozaffari F. Evaluation of the effect of music on anxiety level of patients hospitalized in cardiac wards before angiography. Medsurg Nurs J 2016; 5(2):13-8. Foji S, Tadayonfar MA, Mohsenpour M, et al. The study of the effect of guided imagery on pain, anxiety and some other hemodynamic factors in patients undergoing coronary angiography. Complement Ther Clin Pract 2015; 21(2):119-23. Mahmoudirad G, Ghaedi Mosolo M, Bahrami H. Effect of foot reflexology on anxiety of patients undergoing coronary angiography. Iran J Crit Care Nurs 2014;6(4):235-42. Vardanjani MM, Alavi NM, Razavi NS, et al. A randomizedcontrolled trial examining the effects of reflexology on anxiety of patients undergoing coronary angiography. Nurs Midwifery Stud 2013;2(3):3-9. Tahmasbi H, Mahmoodi G, Mokhberi V, et al. The impact of aromatherapy on the anxiety of patients experiencing coronary angiography. Zahedan J Res Med Sci 2012;14(3):51-5. Mei L, Miao X, Chen H, et al. Effectiveness of Chinese hand massage on anxiety among patients awaiting coronary angiography: a randomized controlled trial. J Cardiovasc Nurs 2017;32(2):196-203. Moradipanah F, Mohammadi E, Mohammadil A. Effect of music on anxiety, stress, and depression levels in patients undergoing coronary angiography. East Mediterr Health J 2009;15(3):639-47. Heidari F, Rejeh N, Heravi-Karimooi M, et al. Effect of short-term hand reflexology on anxiety in patients before coronary angiography: a randomized placebo controlled trial. Eur J Integr Med 2017;16:1-7.
Vol. - No. -
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
25. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52(6): 377-84. 26. Liu Y, Petrini MA. Effects of music therapy on pain, anxiety, and vital signs in patients after thoracic surgery. Complement Ther Med 2015;23(5):714-8. 27. Evans D. The effectiveness of music as an intervention for hospital patients: a systematic review. J Adv Nurs 2002; 37(1):8-18. 28. Yang Z, Jiang H. Investigation on analgesic mechanism of acupointfinger-pressure massage onlumbago. J Tradit Chin Med 1994;14(1):35Y40. 29. Kunikata H, Watanabe K, Miyoshi M, et al. The effects measurement of hand massage by the autonomic activity and psychological indicators. J Med Invest 2012;59(1–2):206-12. 30. Sadeghimoghaddam S, Alavi M, Mehrabi T, et al. The effect of two methods of relaxation and prayer therapy on anxiety and hope in patients with coronary artery disease: A quasiexperimental study. Iran J Nurs Midwifery Res 2019;24(2): 102. 31. Gerogianni G, Babatsikou F, Polikandrioti M, et al. Management of anxiety and depression in haemodialysis patients: the role of non-pharmacological methods. Int Urol Nephrol 2019;51(1):113-8.
PAGE 9
32. Karadag E, Samancioglu S, Ozden D, et al. Effects of aromatherapy on sleep quality and anxiety of patients. Nurs Crit Care 2017;22(2):105-12. 33. Cho MY, Min ES, Hur MH, et al. Effects of aromatherapy on the anxiety, vital signs, and sleep quality of percutaneous coronary intervention patients in intensive care units. Evid Based Complement Alternat Med 2013;2013:381381. 34. Shiina Y, Funabashi N, Lee K, et al. Relaxation effects of lavender aromatherapy improve coronary flow velocity reserve in healthy men evaluated by transthoracic Doppler echocardiography. Int J Cardiol 2008;129(2):193-7. 35. Antall GF, Kresevic D. The use of guided imagery to manage pain in an elderly orthopaedic population. Orthop Nurs 2004; 23(5):335-40. 36. Hernandez-Guzman L, Gonzalez S, L opez F. Effect of guided imagery on children’s social performance. Behav Cogn Psychother 2002;30(4):471-83. 37. Haipin LS, Speir AM, CapoBianco P, et al. Guided imagery in cardiac surgery. Outcomes Manag 2002;6:132-7. 38. Tekur P, Nagarathna R, Chametcha S, et al. A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: an RCT. Complement Ther Med 2012;20(3):107-18. 39. Satyapriya M, Nagarathna R, Padmalatha V, et al. Effect of integrated yoga on anxiety, depression & well-being in normal pregnancy. Complement Ther Clin Pract 2013;19(4):230-6.
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
PAGE 1
Efficacy of complementary interventions for management of anxiety in patients undergoing coronary angiography: A rapid systematic review Mina Bordbar, MScN, Zhila Fereidouni, PhD, Morteza Kameli Morandini, MSN, and Majid Najafi Kalyani, PhD
Coronary angiography (CAG) is an invasive and anxiety-provoking procedure for many patients. Psychological problems, especially anxiety, are the main concern of nurses taking care of these patients before the procedure. This rapid systematic review aimed to assess the efficacy of interventions for management of anxiety in patients undergoing CAG. In this study, all published, peer-reviewed, English-language interventional studies from 2009 to 2018 were identified in a search of Scopus, PubMed, and Google Scholar databases. The relevant studies were assessed using a quality assessment checklist. All included studies were assessed by 2 researchers. Finally, 15 studies with 1,312 participants that evaluated the effects of complementary methods on management of anxiety in patients undergoing CAG were included. The findings of this rapid systematic review suggested that complementary and nonpharmacological methods, such as music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga, could be used effectively for management of anxiety in patients undergoing CAG. (J Vasc Nurs 2019;-:1-9)
INTRODUCTION Cardiovascular disease (CVD) is the most common cause of mortality worldwide.1 Among CVDs, which include a wide range of diseases, coronary artery disease (CAD) is the most common and the most prominent cause of deaths resulting from CVDs.2 Different invasive and noninvasive methods are used to diagnose CAD.3,4 One of the most common and accurate diagnostic tests for this disease is coronary angiography (CAG), which shows the extent and severity of coronary artery stenosis.3,4 Because of its high accuracy, CAG is known as the golden test and standard diagnosis of CAD.3–5 Despite its various advantages in making an accurate diagnosis, CAG causes psychological problems due to its invasive nature.5 One of the most common psychological problems in patients undergoing this procedure is anxiety.6,7 Studies have shown high anxiety From the Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran; Assistant Professor, School of Nursing, Fasa University of Medical Sciences, Fasa, Iran; Faculty of Medicine, Department of Nursing, Sari Branch, Islamic Azad University, Sari, Iran; Associate Professor, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran. Corresponding author: Majid Najafi Kalyani, PhD, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran (E-mail: [email protected]).
levels in these patients.4,7 The waiting time, fear of death, lack of knowledge, and results of angiography have been listed as the main causes of anxiety in these patients.4,5 High levels of anxiety in patients undergoing CAG increase the secretion of catecholamines and enhance the burden of cardiovascular and chest pain, which can endanger the patients’ well-being in the catheterization laboratory.3,5 To manage anxiety in patients undergoing CAG, pharmacological and nonpharmacological methods have been used.8 Nonpharmacological methods include a range of interventions that are more widely used due to lower cost, fewer complications, and ease of implementation in clinic setting.9,10 One of the nonpharmacological methods that has been more promising in the recent years is the use of complementary therapies as part of or on the side of nursing interventions for management of anxiety in these patients. Several studies have been undertaken on the impact of complementary methods such as music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga on anxiety management among patients under CAG.10–24 Considering the different results about the most effective methods in reducing anxiety among these patients and the importance of anxiety control in patients undergoing CAG, using of complementary therapies as a safe, low-cost, and easy method to manage this problem seems necessary. This study aims to investigate the studies carried out on the use of complementary therapies for anxiety control in patients undergoing CAG.
METHODS 1062-0303/$36.00 Ó 2019 Society for Vascular Nursing. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvn.2019.12.005
Study design This rapid systematic review aimed at summarizing the best available evidence related to the efficacy of complementary therapies in managing anxiety in patients undergoing CAG.
PAGE 2
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
- 2020
Search strategy
Data extraction
Scopus, PubMed, and Google Scholar databases were searched using keywords such as coronary angiography, anxiety, nonpharmacological interventions, nursing interventions, and complementary therapies during 2009–2018. To achieve these studies, all published English-language articles were examined separately and in combination with each other to find the relevant studies. The searched studies were imported into EndNote X8 (Clarivate Analytics) for assessment and management.
The initial search revealed 138 studies. These were reviewed for eligibility by 2 researchers in terms of relevancy and quality. Eventually, 15 studies were included in the rapid systematic review. The quality of the studies was examined based on the critical appraisal checklist for articles. In this study, the checklist presented by Downs and Black25 was used for critical appraisal of the studies. The final studies were reviewed by 2 researchers. Then, the name of the author, year of the study, country, sample size, study design, type of intervention, anxiety measuring instrument, and the overall study result were extracted using a standard form.
Selection of studies The main criterion for inclusion of studies into this rapid systematic review was the application of complementary therapies and nursing interventions for anxiety management in patients undergoing CAG. The inclusion criteria of this study were possessing an interventional design, having a control group, reporting anxiety score in patients as a mean value, carrying out interventions based on one or more practices of complementary therapies, and using an appropriate instrument for measuring anxiety in angiography patients. The exclusion criteria were lack of the mean anxiety score, being a single group study, lack of a control group, using pharmacological methods to treat anxiety in patients, and lack of an appropriate quality. It should be noted that the studies covering the period from 2009 to 2018 were included in the study, while those conducted before 2009 were excluded. After studying the full texts of the articles by 2 researchers, based on the inclusion and exclusion criteria, appropriate articles were included in the study as shown in Figure 1. All selected articles were discussed by 2 researchers, and then the final articles were included by the agreement between these researchers.
Eligibility criteria In this study, 4 main eligibility criteria, that is, Population (P), Intervention (I), Comparison (C), and Outcome (O), were used to review the studies as follows: P: all patients undergoing CAG, I: complementary therapies used to manage anxiety, C: routine care versus complementary therapies, and O: anxiety score as the only studied outcome in patients.
Figure 1. Flow diagram of the studies selection.
RESULTS
Characteristics of the studies From 138 studies in the initial search, 15 studies were maintained. These 15 studies were conducted on 1,312 participants. The features and findings of the studies included in this rapid systematic review have been presented in Table 1. Considering the type of intervention used to manage anxiety in patients undergoing CAG, these studies were categorized into 6 groups, including music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga. The clinical trial method was used in the methodology of all studies (100%). In addition, patients’ anxiety level was the main outcome of these studies, which was evaluated through various tools. The most commonly used tool in the majority of studies (78%) was Spielberger’s State-Trait Anxiety Inventory (STAI).11–21,24 This tool consisted of 40 expressions to determine 2 domains of overt (20 questions) and covert (20 questions) anxiety. The questions of this tool were measured from 1 to 4 based on Likert 4-degree scale. The total scores of both covert and overt anxiety scale were in the range of 20–80.21 Other used tools (22%) for measuring anxiety were Beck Anxiety Inventory;10 Hamilton Anxiety Rating Scale;22 and Depression, Anxiety, Stress Scale.23
Vol. - No. -
TABLE 1 CHARACTERISTICS OF THE REVIEWED STUDIES
Year
Country
Design
Participants
Intervention
Moazami Goudarzi et al10
2018
Iran
RCT
Total: 60 Intervention group: 30 Control group: 30
Iran
RCT
Total: 150 Intervention: 50 Control: 50 Placebo: 50
2017
Iran
RCT
Total: 80 Intervention: 40 Control: 40
Ziyaeifard et al13
2017
Iran
RCT
Total: 80 Intervention: 40 Control: 40
Rejeh et al14
2016
Iran
RCT
Total: 130 Intervention: 65 Control: 65
Benson’s relaxation technique was performed for 15– 20 minutes. The patient lay on the bed and an audio file containing relaxing words was played. Reflexology was provided through compressing and stimulating the solar plexus, heart, and pituitary reflex points at the plantar surface of the participants’ feet for 20 minutes. Massage with thumb and with the left hand and then moved to the right hand, started from the forearm moving to the wrist, palm, back of the hand, and finally the fingers. The massage was repeated 8 to 10 times. The patients smelled a piece of cotton wool soaked in 5 drops of lavender essential oil at a distance of 5 cm from the nose with deep inhalations for 5 minutes. Patients were asked to listen to pleasant natural sounds.
Ramezanibadr et al11
2018
Mobini-Bidgoli et al12
Outcome Measure and Tool
Findings Significant difference between the patients’ anxiety levels before and after the intervention (P < .05).
SAI
The level of state anxiety was significantly lower in the intervention group compared to the placebo and control groups (P < .05).
SAI
The mean anxiety level decreased in the intervention group after the intervention (P = .0001).
SAI
The level of anxiety decreased significantly in the intervention group in comparison to the control group (P < .05).
SAI
The intervention group displayed significantly lower anxiety levels compared to the control group during the intervention (P = .001). (Continued)
PAGE 3
BAI
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
Author
PAGE 4
TABLE 1 CONTINUED
Author
Country
Design
Participants
Tahmasbi and Hasani15
2016
Iran
RCT
Total: 70 Intervention: 35 Control: 35
Mobini Bidgoli et al16
2016
Iran
RCT
Total: 80 Intervention: 40 Control: 40
Pourmovahed et al17
2016
Iran
RCT
Foji et al18
2015
Iran
RCT
Total: 70 Intervention: 35 Control: 35 Total: 62 Intervention: 31 Control: 31
Mahmoudirad et al19
2014
Iran
RCT
Total: 70 Intervention: 35 Control: 35
Molavi Vardanjani et al20
2013
Iran
RCT
Total: 100 Intervention: 50 Control: 50
Intervention
Outcome Measure and Tool
Findings
SAI
Use of Benson’s relaxation technique significantly decreased the anxiety level in the intervention group (P = .0001).
SAI
The mean anxiety score significantly decreased in the intervention group after the intervention (P = .0001).
SAI
The intervention protocol included 30 minutes of general foot massage and stimulation of 3 reflex points, including solar plexus, pituitary gland, and the heart.
SAI
A significant difference was observed between the groups after the intervention (P = .008). The level of anxiety decreased significantly in the guided imagery group after the intervention (P < .05). There was a significant difference between the 2 groups’ anxiety mean scores after the intervention (P < .001). The mean range of anxiety decreased in the reflexology group (P = .0001).
SAI
SAI
- 2020
An audio file with recorded instructions on Benson’s relaxation exercises was prepared. The exercises were performed by the patients in the presence of the researcher 1 day before angiography. This state was maintained for 20 minutes. Patients performed sukha pranayama exercises. They were trained to breathe slowly and rhythmically at a rate of 10 breathings per minute for 5 consecutive minutes. The intervention group listened to music for 20 minutes 1 hour before angiography. The intervention group participants were asked to listen to a guided imagery CD for 18 minutes. Patients received foot reflexology for 20 minutes.
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
Year
Iran
RCT
Total: 91 Intervention: 45 Control: 46
Mei et al22
2012
China
RCT
Tota: 100 Intervention: 50 Control: 50
Moradipanah et al23
2009
Iran
RCT
Total: 74 Intervention: 37 Control: 37
Heidari et al24
2017
Iran
RCT
Total: 90 Intervention: 45 Placebo: 45
In the intervention group, 2 drops of Lavendula were dropped on cotton balls in a pot with the volume of 10 mL using a dropper. The patients were required to keep it at a distance of 5 cm from their noses and to sniff for 3 minutes. The intervention group received Chinese hand massage care in conjunction with the same conventional therapies and care as the control group. The intervention group was given a tape player and a music cassette. The 20-minute tape consisted of 3 pieces of relaxing music. Hand reflexology was performed in the intervention group 20 minutes prior to coronary angiography.
SAI
The anxiety level decreased significantly in the intervention group compared to the control group after aromatherapy (P < .0001).
Hamilton anxiety rating scale
The anxiety scores significantly decreased in the intervention group (P < .01).
DASS-21
There was a significant decrease in the mean score of state anxiety in the intervention group (P = .006).
SAI
In the intervention group, the mean level of state anxiety decreased from 49.82 1.74 at baseline to 42.67 1.47 after the intervention (P = .0001).
BAI = Beck Anxiety Inventory; CD = compact disc; DASS-21 = Depression, Anxiety, Stress Scale; RCT = randomized clinical trial; SAI = Spielberger’s State-Trait Anxiety Inventory.
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
2012
Vol. - No. -
Tahmasbi et al21
PAGE 5
PAGE 6
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
- 2020
Music therapy
Benson’s relaxation technique
Three studies were conducted to examine the effect of music therapy on controlling the anxiety of patients undergoing CAG. All these studies showed that music caused a general reduction in the anxiety of patients undergoing CAG. The study conducted by Rejeh et al14 on 130 patients in control and intervention groups showed that hearing music (pleasant natural sound) before angiography for 20 minutes significantly decreased the intervention group’s anxiety score (by STAI) compared with that of the control group (anxiety score differences = 16). In another study, Moradipanah et al23 randomly divided 74 patients into control and intervention groups. In that study, a relaxing music with slow and steady rhythm was played for the intervention group for 20 minutes. The results showed that listening to music decreased the intervention group’s mean score of anxiety from 6.83 4.14 to 2.83 3.55.23 Pourmovahed et al17 also conducted a clinical trial on 70 candidates for CAG. They randomly divided the patients in control and intervention groups. Patients in the intervention group listened to a relaxing music (sound of nature) for 20 minutes before undergoing CAG. The results showed that listening to music significantly changed the intervention group’s anxiety score from 48.45 6.63 (before the intervention) to 44.28 5.21 (after the intervention).17 The aforementioned studies indicated the positive effects of music on reduction of anxiety in patients undergoing CAG.
Two studies with 130 participants were conducted on the effect of Benson’s relaxation technique (relaxation exercises) on controlling the anxiety of patients undergoing CAG. Moazami Goudarzi et al10 performed Benson’s relaxation technique by simultaneous voice training before coronary angiography for the intervention group patients for 15–20 minutes. The results indicated a significant improvement between the patients’ anxiety scores before and after the intervention.11 In a study conducted by Tahmasbi and Hasani,15 70 patients were randomly divided into control and intervention groups. Patients in the intervention group received the audio file (with headphones) of Benson’s relaxation technique (recorded instructions on relaxation exercises) before coronary angiography for 20 minutes. The results showed that Benson’s relaxation technique significantly decreased anxiety among the patients in the intervention group.15
Reflexology There were 6 studies that assessed the effect of reflexology on anxiety in 590 patients. In a study conducted by Mei et al22 in China, 100 patients were randomly divided into control and intervention groups. Hand massage using Chinese method consisted of 3 sequent points (Fengchi [EX-HN5], Shenmen [GB20], Taiyang [HT7]). It was done 15 minutes a day for 3 days before coronary angiography on the patients in the intervention group. Based on the results, Chinese massage significantly decreased the anxiety score.22 In a study conducted by Molavi Vardanjani et al,20 foot massage by stimulation of 3 reflexology area for 30 minutes 1 day before angiography caused a significant decrease in the anxiety score of 50 patients included in the intervention group. Mobini Bidgoli et al12 assessed the effect of hand reflexology through the 6 reflexology points on anxiety level of 80 patients undergoing CAG. In that study, the patients’ anxiety level was measured through STAI (STAI). The results showed that hand reflexology led to a significant decrease in the intervention group’s anxiety score after the intervention (55.47) compared with that at the baseline (57.54).12 Mahmoudirad et al19 reported that foot reflexology through foot’s solar grid point for 20 minutes caused a significant decrease in the experimental group’s mean score of anxiety compared with that of the control group. Ramezanibadr et al11 also investigated the effect of foot reflexology through compressing and stimulating the solar plexus, heart, and pituitary reflex points on 150 male patients undergoing CAG. In that study, foot reflexology significantly decreased the anxiety scores of patients in the intervention group compared with those of the control and placebo groups.11 Similarly, Heidari et al24 found that applying general hand massage was associated with a decrease in the patients’ anxiety mean scores.
Aromatherapy Two studies were conducted to investigate the effect of aromatherapy on controlling the anxiety of patients undergoing CAG. Tahmasbi et al21 used 10 cc of Lavendula extract (aromatic agent) for the intervention group patients for 3 minutes. After analyzing the patients’ anxiety levels by STAI, the results showed a significant decrease in the intervention group patients’ anxiety levels compared with before the intervention.21 The other study was conducted by Ziyaeifard et al,13 which showed that smelling 5 drops of lavender oil (a strong aromatic agent) at a distance of 5 cm from the nose for 5 minutes decreased anxiety levels (assessed by STAI) among patients undergoing CAG.
Guided imagery A study with 62 participants was conducted to investigate the effect of guided imagery on controlling the anxiety of patients undergoing CAG. Foji et al18 demonstrated that using a compact disc of guided imagery (approved by researchers and ethics committee) for 18 minutes through headphones decreased the anxiety score from 103.67 13.9 (before the intervention) to 89.25 11.03 (after the intervention). In this study, the patients were put in a quit environment while listening to audio crating a guided mental image, and their anxiety was assessed by STAI. Thus, the researchers approved that guided imagery could be used as an effective method to decrease anxiety levels among patients undergoing CAG.18
Yoga Mobini Bidgoli et al16 conducted a study to investigate the effect of sukha pranayama technique as one of the yoga methods on controlling the anxiety of patients undergoing CAG. In that study, 80 patients were randomly divided into control and intervention groups. In the intervention group, the patients performed sukha pranayama breathing exercises rhythmically and slowly for 5 minutes. The results revealed that the patients’ anxiety scores (assessed by STAI) decreased from 53.37 (before the intervention) to 40.75 (after the intervention).16 Hence, this easy and noninvasive technique was recommended to be used for controlling patients’ anxiety.
Vol. - No. -
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
DISCUSSION This rapid systematic review study showed that application of complementary therapies might help reduce anxiety in patients undergoing CAG. A review on 3 studies indicated that application of music therapy ended up reducing the level of anxiety among these patients.14,17,23 According to these studies, listening to music for 20 minutes before CAG was reportedly effective in reducing the patients’ anxiety scores.14,17,23 As patients often experience high levels of anxiety before CAG,3–7 it seems appropriate to use nonpharmaceutical interventions, such as music therapy.26 Effectiveness of music therapy in reducing the level of anxiety among patients during normal care was proven in a systematic review study performed by Evan et al.27 However, given the wide range of music therapy methods and music types, it is necessary to undertake further research on this issue. Reflexology has been introduced as an effective approach to anxiety reduction among patients undergoing CAG according to 6 studies including 590 participants. These 6 studies examined different methods of foot massage, hand massage, and Chinese massage.11,12,19,20,22,24 For example, Ramezanibadr et al11 performed foot massage for 20 minutes, while Molavi-Vardanjani et al20 examined 30-minute foot massage together with stimulation of different reflex points. Despite the effectiveness of this method in reducing the patients’ anxiety levels, the literature has proposed no single universal method for achieving this goal. According to the results of the research performed so far, a possible cause of this effectiveness is the enhanced activity of parasympathetic neural system and reduced activity of the sympathetic neural system in decreasing the levels of anxiety.28,29 While performing this method, it is recommended to pay adequate attention to differences in actual practice of the interventions, duration of the intervention, patient’s waiting time before CAG, and personal differences among different patients. Studies conducted on a total of 130 patients undergoing CAG revealed that application of Benson’s relaxation technique ended up reducing their anxiety scores. In a study performed by Tahmasbi and Hasani,15 a 20-minute relaxation technique succeeded to reduce the patients’ anxiety levels. Moazami Goudarzi et al10 also performed a study and reported the effectiveness of a 15- to 20-minute relaxation procedure in lowering the anxiety scores. In the same vein, the results of the study performed by SadeghiMoghadam et al30 on patients engaged with CAD and the one performed by Georgianni et al31 on hemodialysis patients showed that application of Benson’s relaxation technique reduced the patients’ anxiety levels. Given the limited number of studies carried out on the effectiveness of this method in lowering the level of anxiety among patients undergoing CAG, one should pay attention to factors such as the intervention duration and the best protocol to apply the intervention. Easy application, low cost, and nonpharmaceutical nature of this method as an effective nursing intervention highlight the necessity of further research in this area. Aromatherapy has been introduced as an easy, nonpharmaceutical method for controlling patients’ anxiety levels. The findings of 2 studies performed by Ziayifard et al13 and Tahmasbi et al21 showed that the patients experienced lower levels of anxiety in case of breathing aromatic substances before CAG.
PAGE 7
Application of aromatherapy was also reportedly effective in reducing the problems experienced by other patients. According to Ezgi Karadag et al,32 application of aromatherapy ended up reducing the level of anxiety while enhancing the sleep quality among the patients hospitalized in intensive care units. In another research, Mi-Yeon Cho et al33 indicated that aromatherapy was associated with reduced anxiety and enhanced sleep quality among the patients subjected to coronary angioplasty. Moreover, Shiina et al34 emphasized the impact of aromatherapy on improvement of coronary artery blood circulation. Considering the increase in the anxiety level among patients undergoing CAG and the significant impact of anxiety on the patients’ physical and mental performances, this nonpharmacological and lowcost method is recommended to be applied for taking care of such patients. However, given the limitations of the existing literature on the impact of aromatherapy on patients’ anxiety levels, further research on the issue is warranted. Few studies found in this research were those related to the impacts of guided imagery and yoga on anxiety control among patients undergoing CAG. The study performed by Foji et al18 showed that application of guided imagery was associated with lower anxiety scores. Evidence has emphasized the use of this technique as a low-risk, safe, and nonpharmacological approach for patients.35–37 Given the need for patients’ collaboration and participation when it comes to the application of this method, one may pay attention to this need to enhance the efficiency of this care method.18 Furthermore, a study with 80 participants confirmed the effectiveness of yoga in anxiety reduction. In that study, Mobini Bidgoli et al16 used sukha pranayama exercises and found that rhythmic and low-pace performance of these exercises resulted in a significant decline in anxiety scores among the patients undergoing CAG. The positive effect of this method on lowering anxiety levels among patients suffering from back pain was also reported in a study by Tekur et al.38 It was effective in lowering anxiety levels among pregnant women, as well.39 Considering the variety of yoga exercises, one should pay attention to such considerations as the duration of exercises, patient’s background conditions, and time of practicing the exercises. Indeed, nurses and other medical staff have to be trained regarding this method and its application for patients. Yet, further research is required to be conducted on the issue. A strong point of this study was the inclusion and investigation of all studies performed on the effects of complementary therapies among patients undergoing CAG. Although the quality of the studies was considered herein, the present research suffered from limitations such as differences in the sample size as well as limited geographical locations where the studies were performed. Another study limitation was that different researchers had followed various approaches to the application of the same intervention.
CONCLUSION This rapid systematic review revealed that complementary therapies, such as music therapy, reflexology, Benson’s relaxation technique, aromatherapy, guided imagery, and yoga, could be used as effective interventions separately or in conjunction with nursing interventions for reducing the level of anxiety among the patients undergoing CAG. Although the wide variety
PAGE 8
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
of the studies performed so far makes it difficult to draw any accurate conclusion, the findings indicated preliminarily that the use of complementary therapies was effective in reducing the level of anxiety among the patients undergoing CAG. Yet, application of these methods for taking care of patients undergoing CAG requires further researches to determine definitive methods.
11.
AUTHORS’ CONTRIBUTION
12.
M.B., Z.F., M.K.M., and M.N.K. developed the study design and conception, searched for and extracted the data, and wrote and finally approved the manuscript.
13.
DISCLOSURE None declared.
14.
ACKNOWLEDGMENTS This article was extracted from a Master’s thesis written by M.B. and was supported by Fasa University of Medical Sciences. The authors would like to thank Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript.
15.
16.
REFERENCES 1. Loucks EB, Lynch JW, Pilote L, et al. Life-course socioeconomic position and incidence of coronary heart disease: the Framingham Offspring Study. Am J Epidemiol 2009; 169(7):829-36. 2. Woods SL, Froelicher ES, Motzer SA, et al. Cardiac nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. 3. Kalyani MN, Sharif F, Ahmadi F, et al. Iranian patient’s expectations about coronary angiography: a qualitative study. Iran J Nurs Midwifery Res 2013;18(3):180. 4. Molazem Z, Shahabfard Z, Askari A, et al. Effects of a peerled group education on fear, anxiety and depression levels of patients undergoing coronary angiography. Invest Educ Enferm 2018;36(1):e13. 5. Sharif F, Kalyani MN, Ahmadi F, et al. In the shadow of perceived threat: the live experience of Iranian patients candidate for undergoing coronary angiography. J Vasc Nurs 2018;36(3):140-4. 6. Lunden MH, Bengtson A, Lundgren SM. Hours during and after coronary intervention and angiography. Clin Nurs Res 2006;15(4):274-89. 7. Uzun S, Vural H, Uzun M, et al. State and trait anxiety levels before coronary angiography. J Clin Nurs 2008;17(5):602-7. 8. Carroll DL, Malecki-Ketchell A, Astin F. Non-pharmacological interventions to reduce psychological distress in patients undergoing diagnostic cardiac catheterization: a rapid review. Eur J Cardiovasc Nurs 2017;16(2):92-103. 9. Williams A, Ishimine P. Non-pharmacologic management of pain and anxiety in the pediatric patient. Curr Emerg Hosp Med Rep 2016;4(1):26-31. 10. Goudarzi YM, Ghadirian F, Vahedian A, et al. The effect of benson relaxation on the anxiety of patients under radial
17.
18.
19.
20.
21.
22.
23.
24.
- 2020
angiography: a randomized clinical trial. Crit Care Nurs 2018;11(1):e65623. Ramezanibadr F, Amini K, Hossaingholipor K, et al. The impacts of foot reflexology on anxiety among male candidates for coronary angiography: a three-group single-blind randomized clinical trial. Complement Ther Clin Pract 2018; 32:200-4. Mobini-Bidgoli M, Taghadosi M, Gilasi H, et al. The effect of hand reflexology on anxiety in patients undergoing coronary angiography: a single-blind randomized controlled trial. Complement Ther Clin Pract 2017;27:31-6. Ziyaeifard M, Zahedmehr A, Ferasatkish R, et al. Effects of lavender oil inhalation on anxiety and pain in patients undergoing coronary angiography. Iran Heart J 2017; 18(1):44-50. Rejeh N, Heravi-Karimooi M, Tadrisi SD, et al. The impact of listening to pleasant natural sounds on anxiety and physiologic parameters in patients undergoing coronary angiography: a pragmatic quasi-randomized-controlled trial. Complement Ther Clin Pract 2016;25:42-51. Tahmasbi H, Hasani S. Effect of Benson’s relaxation technique on the anxiety of patients undergoing coronary angiography: a randomized control trial. J Nurs Midwifery Sci 2016;3(1):8-14. Bidgoli MM, Taghadosi M, Gilasi H, et al. The effect of sukha pranayama on anxiety in patients undergoing coronary angiography: a single-blind randomized controlled trial. J Cardiovasc Thorac Res 2016;8(4):170. Pourmovahed Z, Tavangar H, Mozaffari F. Evaluation of the effect of music on anxiety level of patients hospitalized in cardiac wards before angiography. Medsurg Nurs J 2016; 5(2):13-8. Foji S, Tadayonfar MA, Mohsenpour M, et al. The study of the effect of guided imagery on pain, anxiety and some other hemodynamic factors in patients undergoing coronary angiography. Complement Ther Clin Pract 2015; 21(2):119-23. Mahmoudirad G, Ghaedi Mosolo M, Bahrami H. Effect of foot reflexology on anxiety of patients undergoing coronary angiography. Iran J Crit Care Nurs 2014;6(4):235-42. Vardanjani MM, Alavi NM, Razavi NS, et al. A randomizedcontrolled trial examining the effects of reflexology on anxiety of patients undergoing coronary angiography. Nurs Midwifery Stud 2013;2(3):3-9. Tahmasbi H, Mahmoodi G, Mokhberi V, et al. The impact of aromatherapy on the anxiety of patients experiencing coronary angiography. Zahedan J Res Med Sci 2012;14(3):51-5. Mei L, Miao X, Chen H, et al. Effectiveness of Chinese hand massage on anxiety among patients awaiting coronary angiography: a randomized controlled trial. J Cardiovasc Nurs 2017;32(2):196-203. Moradipanah F, Mohammadi E, Mohammadil A. Effect of music on anxiety, stress, and depression levels in patients undergoing coronary angiography. East Mediterr Health J 2009;15(3):639-47. Heidari F, Rejeh N, Heravi-Karimooi M, et al. Effect of short-term hand reflexology on anxiety in patients before coronary angiography: a randomized placebo controlled trial. Eur J Integr Med 2017;16:1-7.
Vol. - No. -
JOURNAL OF VASCULAR NURSING www.sciencedirect.com/journal/journal-of-vascular-nursing
25. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52(6): 377-84. 26. Liu Y, Petrini MA. Effects of music therapy on pain, anxiety, and vital signs in patients after thoracic surgery. Complement Ther Med 2015;23(5):714-8. 27. Evans D. The effectiveness of music as an intervention for hospital patients: a systematic review. J Adv Nurs 2002; 37(1):8-18. 28. Yang Z, Jiang H. Investigation on analgesic mechanism of acupointfinger-pressure massage onlumbago. J Tradit Chin Med 1994;14(1):35Y40. 29. Kunikata H, Watanabe K, Miyoshi M, et al. The effects measurement of hand massage by the autonomic activity and psychological indicators. J Med Invest 2012;59(1–2):206-12. 30. Sadeghimoghaddam S, Alavi M, Mehrabi T, et al. The effect of two methods of relaxation and prayer therapy on anxiety and hope in patients with coronary artery disease: A quasiexperimental study. Iran J Nurs Midwifery Res 2019;24(2): 102. 31. Gerogianni G, Babatsikou F, Polikandrioti M, et al. Management of anxiety and depression in haemodialysis patients: the role of non-pharmacological methods. Int Urol Nephrol 2019;51(1):113-8.
PAGE 9
32. Karadag E, Samancioglu S, Ozden D, et al. Effects of aromatherapy on sleep quality and anxiety of patients. Nurs Crit Care 2017;22(2):105-12. 33. Cho MY, Min ES, Hur MH, et al. Effects of aromatherapy on the anxiety, vital signs, and sleep quality of percutaneous coronary intervention patients in intensive care units. Evid Based Complement Alternat Med 2013;2013:381381. 34. Shiina Y, Funabashi N, Lee K, et al. Relaxation effects of lavender aromatherapy improve coronary flow velocity reserve in healthy men evaluated by transthoracic Doppler echocardiography. Int J Cardiol 2008;129(2):193-7. 35. Antall GF, Kresevic D. The use of guided imagery to manage pain in an elderly orthopaedic population. Orthop Nurs 2004; 23(5):335-40. 36. Hernandez-Guzman L, Gonzalez S, L opez F. Effect of guided imagery on children’s social performance. Behav Cogn Psychother 2002;30(4):471-83. 37. Haipin LS, Speir AM, CapoBianco P, et al. Guided imagery in cardiac surgery. Outcomes Manag 2002;6:132-7. 38. Tekur P, Nagarathna R, Chametcha S, et al. A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: an RCT. Complement Ther Med 2012;20(3):107-18. 39. Satyapriya M, Nagarathna R, Padmalatha V, et al. Effect of integrated yoga on anxiety, depression & well-being in normal pregnancy. Complement Ther Clin Pract 2013;19(4):230-6.