Abstract
Objective:
Patients with diabetes mellitus and coronary heart disease may experience delayed recovery and psychological distress after percutaneous coronary intervention. This study assessed the effects of ward noise management combined with guided imaginative relaxation on postoperative recovery and psychological status.
Methods:
We included 114 patients with coronary heart disease complicated by diabetes mellitus who underwent percutaneous coronary intervention between February 2023 and January 2025. According to the admission period, patients were assigned to the control group (n = 57), receiving routine cardiology nursing care, or the observation group (n = 57), receiving ward noise management combined with guided imagery relaxation in addition to routine care. We assessed anxiety and depression using the Hospital Anxiety and Depression Scale (HADS), sleep quality using the Pittsburgh Sleep Quality Index (PSQI), activities of daily living using the Barthel Index (BI), and pain intensity using the Visual Analog Scale (VAS). We also recorded postoperative length of hospital stay.
Results:
Baseline characteristics and prenursing measure scores showed no significant differences between the two groups (P > 0.05). Before discharge, the observation group had significantly lower HADS-A, HADS-D, PSQI, and VAS scores, and a significantly higher BI score than the control group (all P < 0.001). Postoperative hospital stay was also shorter in the observation group.
Conclusion:
Ward noise management combined with guided imagery relaxation may improve psychological status, sleep quality, pain, and functional recovery in patients with diabetes mellitus and coronary heart disease after percutaneous coronary intervention.
Keywords: coronary artery disease, diabetes mellitus, environmental noise, imagery, psychotherapy, anxiety, depression
KEY MESSAGES
-
(1)
Combined noise management and relaxation therapy significantly improved patients’ mental status, sleep quality, and pain symptoms.
-
(2)
Patients who received the combined nursing measures achieved better functional recovery in daily activities and shorter hospital stay after receiving the combined nursing measures.
-
(3)
This combined nursing approach has clinical value for patients with dual diseases after coronary artery treatment.
INTRODUCTION
As China’s population undergoes rapid demographic aging, the burden of chronic noncommunicable diseases has risen persistently.[1,2] Diabetes mellitus and coronary heart disease are among the most common chronic conditions in the elderly population and frequently coexist, with each influencing the progression of the other. Epidemiological studies have shown that patients with diabetes have a significantly higher risk of developing coronary heart disease. When these two diseases occur concurrently, patients often present with more complex clinical conditions, higher complication rates, and prolonged hospitalization, which place greater demands on medical resources and nursing care.[3]
percutaneous coronary intervention is an important treatment for coronary heart disease.[4] Owing to its minimally invasive nature and relatively rapid postoperative recovery, percutaneous coronary intervention has been widely adopted in clinical practice. Nevertheless, patients may still experience postoperative discomfort, limited mobility, sleep disturbances, and psychological fluctuations after percutaneous coronary intervention. For patients with diabetes complicated by coronary heart disease, perioperative management poses greater challenges owing to chronic metabolic abnormalities and widespread multisystem complications.[5] Consequently, postoperative recovery in this population may be influenced by multiple factors. Therefore, optimizing additional measures beyond routine treatment to promote postoperative recovery has become an important focus of clinical practice.
In recent years, perioperative nursing has gradually shifted from purely physiological support toward a more comprehensive approach addressing physical and psychological well-being. Anxiety and depression are relatively common among patients undergoing cardiovascular procedures and may affect their participation in treatment and rehabilitation activities.[6] Meanwhile, environmental factors within the hospital ward have attracted increasing attention. Among them, noise is considered an important external factor that may interfere with patients’ rest and sleep. Continuous acoustic triggers originating from medical device alarms, bedside nursing procedures, and clinical staff communication represent persistent sensory burdens with detrimental effects on patients’ somatic and psychological conditions.[7,8] guided imagery relaxation is a commonly used psychological nursing measure in which patients are guided through breathing exercises and positive mental imagery to promote relaxation and relieve tension.[9] This method is simple to implement, has a high level of safety, and has been applied in perioperative nursing, chronic disease management, and pain management.
Therefore, this study added ward noise management and guided imagery relaxation to routine nursing care to explore their effects on postoperative recovery, anxiety, and depression in patients with diabetes and coronary heart disease after percutaneous coronary intervention. The study aimed to provide a safe and feasible nursing strategy for patients after percutaneous coronary intervention and to offer clinical evidence for optimizing perioperative nursing models and improving postoperative recovery outcomes.
MATERIALS AND METHODS
Study Population
This retrospective cohort study included 114 patients with coronary heart disease and diabetes who underwent percutaneous coronary intervention in the Department of Cardiology of Changxing People’s Hospital between February 2023 and January 2025. A total of 136 patients with coronary heart disease complicated by diabetes mellitus who received percutaneous coronary intervention were screened for eligibility. Among them, 9 were excluded due to hepatic or renal dysfunction, 7 due to severe cardiac diseases (e.g., arrhythmia or valvular heart disease), and 6 due to a history of psychiatric disorders. Ultimately, 114 patients were included in the final analysis, with 57 patients in the control group and 57 in the observation group. All data were retrospectively extracted from the hospital’s electronic medical record system and nursing documentation system. To ensure data accuracy and consistency, a standardized data extraction form was developed before data collection. Two independent researchers performed data extraction, and all extracted data were cross-checked. In cases of discrepancy, the original medical records were reviewed, and disagreements were resolved through discussion or consultation with a third senior investigator. This process was implemented to minimize information bias and improve the reliability of the collected data. The inclusion criteria were as follows: (1) aged 45 to 75 years; (2) meeting the surgical indications specified in the Chinese Guidelines for percutaneous coronary intervention (2016)[10]; and (3) undergoing percutaneous coronary intervention for the first time. The exclusion criteria were as follows: (1) concomitant hepatic or renal dysfunction; (2) other severe cardiac diseases (e.g., arrhythmia or valvular heart disease); or (3) a history of psychiatric disorders. Two patient groups were defined according to the differential routine nursing measures administered at separate timepoints. Patients admitted between February 2023 and January 2024 received routine cardiology nursing care and were included in the control group (n = 57). Patients admitted between February 2024 and January 2025 received routine cardiology nursing care combined with ward noise management and guided imagery relaxation nursing measures and were included in the observation group (n = 57).
Nursing Measures
Control Group
Routine cardiology nursing care: Patients in the control group received routine postoperative nursing care in the cardiology ward. Routine nursing care consisted of the following components: (1) General nursing care and condition monitoring: After returning to the ward, patients were immediately assessed for consciousness, main complaints (e.g., chest pain, dyspnea, or dizziness), skin perfusion, urine output, and the condition of the puncture-side limb. Continuous electrocardiographic monitoring was performed, and blood pressure, heart rate, respiratory rate, oxygen saturation, and body temperature were monitored regularly. Complications including reperfusion injury, acute heart failure, arrhythmia, acute chest pain, and contrast-agent–related adverse reactions were closely observed. (2) Puncture-site care and bleeding risk monitoring: The puncture site was inspected regularly for bleeding, hematoma formation, and distal limb circulation. Signs of bleeding associated with antithrombotic therapy (e.g., gingival bleeding, epistaxis, hematuria, or melena) were carefully monitored. (3) Pain and comfort care: Pain intensity was evaluated using the Visual Analog Scale (VAS). Postural adjustment and analgesic treatment were provided when necessary. A tranquil ward setting with controlled temperature and humidity was sustained to reduce nocturnal disruptions and facilitate patient sleep. (4) Diabetes management: Blood glucose levels were monitored according to medical orders and recorded to prevent hypoglycemia. Patients were instructed to follow a glucose-controlled, low-salt, and low-fat diet and to adhere to insulin or oral hypoglycemic therapy as prescribed. (5) Medication management and health education: Patients were instructed to take medications such as antiplatelet agents and statins as prescribed and were advised not to discontinue medication without medical consultation. After stabilization of their condition, lifestyle guidance was provided, including smoking cessation, limiting alcohol intake, engaging in appropriate physical activity, and attending regular follow-up visits.
Observation Group
Ward noise management combined with guided imagery relaxation: Patients in the observation group received ward noise management combined with guided imagery relaxation in addition to routine cardiology nursing care.
Ward Noise Management
A noise-management team was established, consisting of the head nurse, responsible nurses, and quality-control nurses. All nursing staff underwent standardized training in noise-control strategies and were tasked with implementing and supervising the nursing measure. The main measures included the following: (1) Patients and their caregivers received education on the adverse effects of environmental noise on sleep quality and cardiovascular stress responses. They were also encouraged to follow the quiet-ward policy. (2) A designated quiet period from 22:00 to 06:00 was established, during which visits and nonurgent procedures were restricted. (3) Medical staff were required to speak quietly and minimize unnecessary nighttime conversations and movement. Doors were closed gently, and carts were moved carefully to reduce noise. (4) Alarm volumes of monitoring devices were adjusted individually according to patient safety requirements, and alarms were addressed promptly to prevent prolonged noise exposure. Medical devices were regularly inspected and serviced to lower operational acoustic output, while cushioning pads were installed on nursing and treatment carts. (5) For patients with sleep difficulties or heightened sensitivity to noise, earplugs or eye masks were provided to further reduce environmental disturbances.
Noise Monitoring
To evaluate the effectiveness of ward noise management measures, environmental noise was monitored using a Class 2 digital sound level meter (SV 973A, SVANTEK, Poland), calibrated before use and compliant with ISO 1996-1:2016 and WHO Environmental Noise Guidelines (2018) for hospital ward noise assessment.[11,12] Monitoring was performed daily throughout hospitalization at three fixed time points, 10:00 and 16:00 for daytime, and 23:00 for nighttime. The meter was placed 1 m from the bedside at head height, recording continuously for 5 min per time point. The A-weighted equivalent continuous sound level [LAeq, dB(A)] was read directly from the instrument. Daytime LAeq was defined as the average of the 10:00 and 16:00 measurements (07:00–23:00), and nighttime LAeq was represented by the 23:00 measurement (23:00–07:00). Mean noise levels recorded throughout the observation period were computed for all patient cohorts, and between-group comparisons were subsequently performed.
Guided Imagery Relaxation
guided imagery relaxation was implemented by trained responsible nurses after the patients’ vital signs had stabilized. The nursing measure was conducted once or twice daily, with each session lasting 10 to 20 minutes, and continued until discharge. Sessions were conducted within a calm, comfortable setting, with patients positioned in either the supine or semi-recumbent posture for physical comfort. (1) Breathing relaxation training: Patients were instructed to perform diaphragmatic breathing by inhaling slowly, pausing briefly, and then exhaling gradually for several cycles to relieve tension. (2) Progressive muscle relaxation: Patients were guided to sequentially relax the muscles of the face, shoulders and neck, upper limbs, trunk, and lower limbs, allowing the entire body to gradually reach a relaxed state. (3) Guided imagery: Through gentle, slow, and standardized verbal guidance, patients were encouraged to imagine themselves in a safe and comfortable environment (e.g., a beach or garden) and to focus on sensory experiences including surrounding sounds, smells, and bodily sensations, thereby promoting emotional calmness and physical relaxation. (4) Completion and evaluation: Upon session completion, patients were gradually guided to regain full awareness. The relaxation status, emotional shifts, and any adverse physical discomfort were assessed and documented.
Outcome Measures
In this retrospective cohort study, demographic, clinical, and outcome data were obtained from the hospital electronic medical record system and nursing records. Comparisons of the following endpoints were conducted between the two groups to evaluate postoperative recovery and psychological status among patients with coronary heart disease and concomitant diabetes mellitus undergoing percutaneous coronary intervention: (1) Anxiety and depression: Anxiety and depression levels were assessed using the Hospital Anxiety and Depression Scale (HADS), which comprises the anxiety subscale (HADS-A) and depression subscale (HADS-D).[13,14] The scale contains 14 items, each scored from 0 to 3, with a total score ranging from 0 to 21 for each subscale. Higher scores indicate more severe anxiety or depression. This scale has good internal consistency (Cronbach’s α = 0.82–0.90) and a test–retest intraclass correlation coefficient (ICC) of 0.81 to 0.87, along with sound construct and criterion validity. The assessment was conducted before the nursing measure and again before discharge by trained nursing staff. (2) Sleep quality: Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI),[15,16] which includes seven components: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. The total score ranges from 0 to 21, with higher scores indicating poorer sleep quality. It has favorable internal consistency (Cronbach’s α = 0.82–0.86) and a test–retest ICC of 0.83 to 0.89, and its validity has been widely verified in clinical research. All assessments were completed at two time points: before the nursing measure and before discharge. (3) Postoperative recovery: Postoperative length of hospital stay served as an objective indicator of patient recovery. Length of stay was defined as the number of days spanning from the start of percutaneous coronary intervention to hospital discharge, representing comprehensive postoperative recovery process and treatment efficiency. (4) Activities of daily living: Activities of daily living were evaluated using the Barthel Index (BI), which includes 10 items (e.g., feeding, dressing, personal hygiene, walking, and toileting).[17,18] The total score ranges from 0 to 100, with higher scores indicating greater independence in daily activities. The index has excellent inter-rater ICC of 0.90 to 0.95 and test–retest ICC of 0.88 to 0.93, as well as satisfactory content and criterion validity. Assessments were performed before the nursing measure and before discharge. (5) Postoperative pain. Pain intensity was assessed using the Visual Analog Scale (VAS), ranging from 0 to 10, where 0 indicates no pain and 10 indicates the most severe pain imaginable.[19,20] This pain scale has test–retest ICC of 0.85–0.92 and high criterion validity in clinical pain evaluation. Pain was evaluated at 24 h after surgery and again before discharge. All scales used in this study have well-established reliability and validity.
Statistical Analysis
Statistical analyses were conducted using R software (version 4.4.1; R Foundation for Statistical Computing, Vienna, Austria). The Shapiro–Wilk test was used to assess the normality of continuous data distribution. Continuous variables were expressed as mean ± standard deviation (x̄±s) and compared between groups using Student’s t-test or the Mann–Whitney U test, as appropriate. Categorical variables were summarized as numbers and percentages (n, %), and compared using the chi-square test. A two-sided P value <0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Changxing People’s Hospital (Approval No. 2025-EC-87). Written informed consent was obtained from all participants before enrolment.
RESULTS
Baseline Characteristics
A total of 114 patients were included, with 57 patients in the observation group and 57 in the control group. Baseline characteristics are shown in Table 1. No significant differences were observed between the two groups in sex, age, prevalence of hypertension, history of diabetes, smoking history, alcohol consumption, body mass index, and glycated hemoglobin levels (all P > 0.05), indicating that the baseline characteristics were comparable between the two groups.
Table 1.
Comparison of General Characteristics between the Observation Group and the Control Group.
| Observation Group (n = 57) | Control Group (n = 57) | χ2/t | P Value | |
|---|---|---|---|---|
| Male, n (%) | 37 (64.9) | 39 (68.4) | 0.15 | 0.70 |
| Age, years (x̄±s) | 60.53 ± 8.54 | 62.82 ± 8.25 | 1.45 | 0.15 |
| Hypertension, n (%) | 27 (47.4) | 33 (57.9) | 1.27 | 0.26 |
| DM duration, years (x̄±s) | 6.51 ± 2.14 | 6.67 ± 2.31 | 0.32 | 0.75 |
| Smoking, n (%) | 31 (54.4) | 23 (40.4) | 2.27 | 0.13 |
| Drinking, n (%) | 25 (43.9) | 20 (35.1) | 0.91 | 0.34 |
| BMI, kg/m2 (x̄±s) | 23.75 ± 1.96 | 24.38 ± 2.66 | 1.44 | 0.15 |
| HbA1c (x̄±s) | 7.04 ± 0.33 | 7.11 ± 0.37 | 1.43 | 0.15 |
BMI = body mass index, DM = diabetes mellitus, HbA1c = glycated hemoglobin
Anxiety and Depression Outcomes
Before the nursing measures, no significant differences were observed between the two groups in HADS-A or HADS-D scores (P > 0.05, Table 2). Before discharge, HADS-A and HADS-D scores were lower in the observation group than in the control group. Specifically, the HADS-A score was 7.42 ± 2.28 in the observation group compared with 9.18 ± 2.09 in the control group (P < 0.001), and the HADS-D score was 6.16 ± 1.80 in the observation group compared with 7.25 ± 1.76 in the control group (P = 0.001).
Table 2.
Comparison of Outcomes between the Observation Group and the Control Group.
| Observation Group (n = 57) | Control Group (n = 57) | t | P Value | ||
|---|---|---|---|---|---|
| HADS-A | Pre-nursing measure | 12.56 ± 4.18 | 12.49 ± 4.44 | 0.09 | 0.93 |
| Pre-discharge | 7.42 ± 2.28 | 9.18 ± 2.09 | 4.24 | <0.001 | |
| HADS-D | Pre-nursing measure | 10.04 ± 4.18 | 10.18 ± 4.69 | 0.17 | 0.87 |
| Pre-discharge | 6.16 ± 1.80 | 7.25 ± 1.76 | 3.29 | 0.001 | |
| PSQI | Pre-nursing measure | 17.70 ± 2.85 | 16.86 ± 2.60 | 1.66 | 0.10 |
| Pre-discharge | 9.54 ± 2.46 | 12.00 ± 2.28 | 5.52 | <0.001 | |
| BI | Pre-nursing measure | 49.47 ± 11.17 | 47.72 ± 13.92 | 0.74 | 0.46 |
| Pre-discharge | 90.26 ± 7.53 | 78.16 ± 8.00 | 8.37 | <0.001 | |
| VAS | Pre-nursing measure | 7.56 ± 1.44 | 7.30 ± 1.39 | 1.00 | 0.32 |
| Pre-discharge | 1.18 ± 1.36 | 3.19 ± 1.43 | 7.52 | <0.001 |
BI = Barthel Index, HADS-A = Hospital Anxiety and Depression Scale-Anxiety subscale, HADS-D = Hospital Anxiety and Depression Scale-Depression subscale, PSQI = Pittsburgh Sleep Quality Index, VAS = Visual Analog Scale.
Sleep Quality and Pain
No significant differences were observed in PSQI or VAS scores between the two groups before the nursing measures (P > 0.05, Table 2). However, before discharge, the PSQI score in the observation group was lower than that in the control group (9.54 ± 2.46 vs. 12.00 ± 2.28, P < 0.001). Similarly, the VAS score was lower in the observation group than in the control group (1.18 ± 1.36 vs. 3.19 ± 1.43, P < 0.001).
Activities of Daily Living
Before the nursing measures, no significant difference was observed in BI scores between the two groups (P > 0.05, Table 2). Before discharge, the BI score in the observation group was higher than that in the control group (90.26 ± 7.53 vs. 78.16 ± 8.00, P < 0.001), indicating better recovery of daily living ability.
Ward Noise Monitoring
The environmental noise levels in the observation group were lower than those in the control group during daytime and nighttime (Table 3). Specifically, the daytime LAeq in the observation group was 49.93 ± 3.86 dB(A), compared with 58.35 ± 3.46 dB(A) in the control group (P < 0.001). Similarly, the nighttime LAeq was 40.53 ± 3.05 dB(A) in the observation group and 43.63 ± 2.61 dB(A) in the control group (P < 0.001), indicating that the ward noise management measures reduced environmental noise levels.
Table 3.
Comparison of Ward Noise Levels between the Two Groups.
| Period | Observation Group (n = 57) | Control Group (n = 57) | t | P Value |
|---|---|---|---|---|
| Daytime LAeq [dB(A)] | 49.93 ± 3.86 | 58.35 ± 3.46 | 12.13 | <0.001 |
| Nighttime LAeq [dB(A)] | 40.53 ± 3.05 | 43.63 ± 2.61 | 5.85 | <0.001 |
dB(A) = A-weighted decibel, LAeq = A-weighted equivalent continuous sound level
Length of Hospital Stay
The postoperative length of hospital stay was shorter in the observation group than in the control group (3.88 ± 0.83 vs. 5.89 ± 0.88 days, P < 0.001, Table 4).
Table 4.
Comparison of Postoperative Length of Hospital Stay between the Two Groups.
| Observation Group | Control Group | t | P Value | |
|---|---|---|---|---|
| Length of hospital stay (days) | 3.88 ± 0.83 | 5.89 ± 0.88 | 12.41 | <0.001 |
DISCUSSION
This study found that, compared with routine cardiac nursing care alone, ward noise management combined with guided imagery relaxation training reduced anxiety and depression scores and improved sleep quality, pain levels, and activities of daily living in patients with coronary heart disease and diabetes after percutaneous coronary intervention. These findings reveal that combined environmental management and psychological relaxation strategies may promote improved postoperative recovery and psychological well-being in this patient population.
Hospital noise should be considered not only an issue of comfort but also an environmental stressor with potential physiological consequences. Previous studies have shown that persistent or sudden noise exposure can trigger arousal responses and activate stress-related neural pathways, leading to stimulation of the hypothalamic–pituitary–adrenal axis and the sympathetic nervous system.[21,22] This activation may increase the release of cortisol and catecholamines and promote inflammatory signaling, which in turn may result in elevated heart rate, blood pressure fluctuations, and increased myocardial oxygen consumption.[23,24,25] In individuals undergoing recovery following percutaneous coronary intervention, a stable hemodynamic state and adequate rest are essential for maintaining myocardial oxygen supply–demand balance. Noise-induced sympathetic activation may therefore interfere with postoperative recovery by sustaining persistent systemic stress physiology. Furthermore, nocturnal noise can disrupt sleep continuity and reduce deep sleep duration, which may impair autonomic regulation, inflammatory balance, and tissue repair processes.[26] Such disturbances may subsequently increase fatigue, irritability, pain sensitivity, and emotional instability, thereby delaying recovery. Guided imagery relaxation is a widely used nonpharmacological psychological intervention that may exert regulatory effects on cognitive, emotional, and physiological processes. Verbal counseling, breathing regulation, and positive imagery enables patients to disengage attention from disease-related distress and environmental stressors, thereby reducing negative emotional responses.[27,28,29,30] Meanwhile, slow breathing and relaxation may enhance parasympathetic activity and reduce sympathetic tone, which may help alleviate stress responses and improve subjective comfort.[31,32] In addition, relaxation training may influence pain processing by modifying cognitive evaluation of physical discomfort and reducing attention-related amplification of pain. These regulatory pathways offer particular clinical benefits to patients undergoing percutaneous coronary intervention, who often remain concerned about complications, recurrent symptoms, and long-term prognosis. For individuals with diabetes, who frequently have longer disease duration and greater comorbidity burden, psychological stress may be even more pronounced. Therefore, combining ward noise management with guided imagery relaxation training may exert synergistic physiological and psychological benefits and support postoperative recovery.
Several limitations should be acknowledged. This study was conducted at a single center with a relatively small sample size. In addition, the outcomes were mainly based on subjective evaluation scales, including anxiety and depression scores, sleep quality, and pain assessment, without objective physiological indicators (e.g., catecholamine levels or biomarkers of myocardial injury). Future multicenter studies incorporating objective indicators may help further clarify the underlying mechanisms and confirm the effectiveness of this intervention.
CONCLUSION
Ward noise management combined with guided imagery relaxation training may help reduce anxiety and depression, improve sleep quality, alleviate pain, and enhance daily functioning in patients with coronary heart disease and diabetes after percutaneous coronary intervention. Such an integrated nursing strategy may yield supplementary improvements in postoperative recovery outcomes. Further prospective studies with objective physiological measures are warranted to confirm its clinical value.
Availability of Data and Materials
The datasets generated and/or analyzed during the current study are not publicly available due to the privacy of the research participants but are available from the corresponding author on reasonable request with the approval of the Ethics Committee of Changxing People’s Hospital.
Author Contributions
YuHua Zhu was responsible for the conception and design of the study, as well as the manuscript drafting. LiLi Wang and ChunYan Huang were responsible for data collection in this study and performed statistical analyses on the collected data. Ao Liu made contributions to the definition of intellectual content of the research, reviewed and revised the manuscript, polished language, and responded to reviewers’ comments. Authors read and approved the final manuscript, took public responsibility for appropriate portions of the content, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or completeness of any part of the work were appropriately investigated and resolved.
Ethics Approval and Consent to Participate
This study was approved by the Ethics Committee of Changxing People’s Hospital (Approval No. 2025-EC-87). Written informed consent was obtained from all participants before enrollment.
Conflicts of Interest
The authors declare that there are no conflicts of interest.
Acknowledgment
The authors acknowledge the support of the nursing and medical staff of the Department of Cardiology, Changxing People’s Hospital, for their assistance in the implementation of nursing interventions and data collection. They also thank the Ethics Committee of Changxing People’s Hospital for the ethical approval of this study.
Funding Statement
This work was supported by the Huzhou Public Welfare Applied Research Project, Huzhou Science and Technology Bureau, Zhejiang Province, China (Grant No. 2025GY158).
REFERENCES
- 1.Lv J, Zhang ZF. Progress and challenges in NCD prevention and control in China. BMJ. 2024;387:q2098. doi: 10.1136/bmj.q2098. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hu X, Yu SJ, Gao YC, et al. Health inequality in the disease burden of non-communicable diseases among the elderly from 1990 to 2021, and projections to 2050: a systematic analysis of global burden of disease study. BMC Geriatr. 2025;25:693. doi: 10.1186/s12877-025-06344-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Gong JY, Morton JI, Chen L, et al. Time trends in mortality from heart failure and atherosclerotic cardiovascular disease in people with and without diabetes: a multi-national population-based study. Lancet Diabetes Endocrinol. 2026;14:20–8. doi: 10.1016/S2213-8587(25)00265-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Collet C, Mahendiran T, Fearon WF, et al. Fractional flow reserve-guided percutaneous coronary intervention versus medical therapy for stable coronary artery disease: long-term results of the FAME 2 trial. Nat Med. 2026;32:318–24. doi: 10.1038/s41591-025-04132-5. [DOI] [PubMed] [Google Scholar]
- 5.van Vliet D, Pinxterhuis TH, Ploumen EH, et al. Impact of diabetes on three-year outcome after coronary stenting in patients with polyvascular atherosclerotic disease—a secondary analysis of the randomized TWENTE trials. Int J Cardiol Heart Vasc. 2025;59:101741. doi: 10.1016/j.ijcha.2025.101741. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Tang X, Liu G, Zeng YJ. Anxiety disorders following percutaneous coronary intervention for acute myocardial infarction: a comprehensive review of clinical manifestations and interventions. World J Psychiatry. 2025;15:110290. doi: 10.5498/wjp.v15.i12.110290. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Alves M, Monteiro E, Nogueira M, et al. Night-time noise and sleep quality in an internal medicine ward in Portugal: an observational study. Acta Med Port. 2024;37:119–25. doi: 10.20344/amp.19042. [DOI] [PubMed] [Google Scholar]
- 8.Sonoda N, Furuki H, Morimoto A. Impact of environmental noise on inpatient outcomes: a scoping review. Worldviews Evid Based Nurs. 2025;22:e70056. doi: 10.1111/wvn.70056. [DOI] [PubMed] [Google Scholar]
- 9.Freeman M, Ayers C, Kondo K, et al. Guided Imagery, Biofeedback, and Hypnosis: A Map of the Evidence [Internet] Washington, DC: Department of Veterans Affairs (US); 2019. [PubMed] [Google Scholar]
- 10.Commitee of Cardiac Rehabilitation and Prevention of Chinese Association of Rehabilitation Medicine. Guidelines for cardiovascular rehabilitation and secondary prevention in China 2018 simplified edition [in Chinese] Zhonghua Nei Ke Za Zhi. 2018;57:802–10. doi: 10.3760/cma.j.issn.0578-1426.2018.11.003. [DOI] [PubMed] [Google Scholar]
- 11.Lempert B. ISO estimates of noise-induced hearing impairment. J Acoust Soc Am. 2019;145:3640. doi: 10.1121/1.5111862. [DOI] [PubMed] [Google Scholar]
- 12.Münzel T, Daiber A, Engelmann N, Röösli M, Kuntic M, Banks JL. Noise causes cardiovascular disease: it’s time to act. J Expo Sci Environ Epidemiol. 2025;35:24–33. doi: 10.1038/s41370-024-00732-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Gough K, Hudson P. Psychometric properties of the Hospital Anxiety and Depression Scale in family caregivers of palliative care patients. J Pain Symptom Manage. 2009;37:797–806. doi: 10.1016/j.jpainsymman.2008.04.012. [DOI] [PubMed] [Google Scholar]
- 14.Kozlov E, McDarby M, Pagano I, Llaneza D, Owen J, Duberstein P. The feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness therapy for caregivers of adults with cognitive impairment. Aging Ment Health. 2022;26:1963–70. doi: 10.1080/13607863.2021.1963949. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Buysse DJ, Reynolds CF, 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213. doi: 10.1016/0165-1781(89)90047-4. [DOI] [PubMed] [Google Scholar]
- 16.Zhong W, Zhao A, Lan H, et al. Sleep quality, antepartum depression and self-harm thoughts in pregnant Chinese women. J Affect Disord. 2023;327:292–8. doi: 10.1016/j.jad.2023.01.127. [DOI] [PubMed] [Google Scholar]
- 17.Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61–5. [PubMed] [Google Scholar]
- 18.Lin CF, Liu HC, Lin SY. Kidney Function and risk of physical and cognitive impairment in older persons with type 2 diabetes at an outpatient clinic with geriatric assessment implementation. Diabetes Metab Syndr Obes. 2022;15:79–91. doi: 10.2147/DMSO.S341935. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Flaherty SA. Pain measurement tools for clinical practice and research. AANA J. 1996;64:133–40. [PubMed] [Google Scholar]
- 20.Li M, Xu A, Chen B. Effects of operating room noise on anxiety and pain in non-general anaesthesia orthopaedic surgery under seamless care and diversified health education. Noise Health. 2025;27:446–57. doi: 10.4103/nah.nah_28_25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Hahad O, Prochaska JH, Daiber A, Muenzel T. Environmental noise-induced effects on stress hormones, oxidative stress, and vascular dysfunction: key factors in the relationship between cerebrocardiovascular and psychological disorders. Oxid Med Cell Longev. 2019;2019:4623109. doi: 10.1155/2019/4623109. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Zhang L, Wu C, Martel DT, West M, Sutton MA, Shore SE. Noise exposure alters glutamatergic and GABAergic synaptic connectivity in the hippocampus and its relevance to tinnitus. Neural Plast. 2021;2021:8833087. doi: 10.1155/2021/8833087. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Münzel T, Schmidt FP, Steven S, Herzog J, Daiber A, Sørensen M. Environmental noise and the cardiovascular system. J Am Coll Cardiol. 2018;71:688–97. doi: 10.1016/j.jacc.2017.12.015. [DOI] [PubMed] [Google Scholar]
- 24.Münzel T, Sørensen M, Schmidt F, et al. The adverse effects of environmental noise exposure on oxidative stress and cardiovascular risk. Antioxid Redox Signal. 2018;28:873–908. doi: 10.1089/ars.2017.7118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Daiber A, Kröller-Schön S, Frenis K, et al. Environmental noise induces the release of stress hormones and inflammatory signaling molecules leading to oxidative stress and vascular dysfunction: signatures of the internal exposome. BioFactors. 2019;45:495–506. doi: 10.1002/biof.1506. [DOI] [PubMed] [Google Scholar]
- 26.Micic G, Zajamsek B, Lechat B, et al. Establishing the acute physiological and sleep disruption characteristics of wind farm versus road traffic noise disturbances in sleep: a randomized controlled trial protocol. Sleep Adv. 2023;4:zpad033. doi: 10.1093/sleepadvances/zpad033. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Holden-Lund C. Effects of relaxation with guided imagery on surgical stress and wound healing. Res Nurs Health. 1988;11:235–44. doi: 10.1002/nur.4770110405. [DOI] [PubMed] [Google Scholar]
- 28.Howland LC, Jallo N, Connelly CD, Pickler RH. Feasibility of a relaxation guided imagery intervention to reduce maternal stress in the NICU. J Obstet Gynecol Neonatal Nurs. 2017;46:532–43. doi: 10.1016/j.jogn.2017.03.004. [DOI] [PubMed] [Google Scholar]
- 29.Weigensberg MJ, Lane CJ, Ávila Q, et al. Imagine HEALTH: results from a randomized pilot lifestyle intervention for obese Latino adolescents using Interactive Guided ImagerySM. BMC Complement Altern Med. 2014;14:28. doi: 10.1186/1472-6882-14-28. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Baider L, Uziely B, De-Nour AK. Progressive muscle relaxation and guided imagery in cancer patients. Gen Hosp Psychiatry. 1994;16:340–7. doi: 10.1016/0163-8343(94)90021-3. [DOI] [PubMed] [Google Scholar]
- 31.Toussaint L, Nguyen QA, Roettger C, et al. Effectiveness of progressive muscle relaxation, deep breathing, and guided imagery in promoting psychological and physiological states of relaxation. Evid Based Complement Alternat Med. 2021;2021:5924040. doi: 10.1155/2021/5924040. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Berntson GG, Cacioppo JT, Quigley KS. Respiratory sinus arrhythmia: autonomic origins, physiological mechanisms, and psychophysiological implications. Psychophysiology. 1993;30:183–96. doi: 10.1111/j.1469-8986.1993.tb01731.x. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available due to the privacy of the research participants but are available from the corresponding author on reasonable request with the approval of the Ethics Committee of Changxing People’s Hospital.