I recently caught up with the members of a Veteran-led band that performs weekly in the local Veteran's hospital cafeteria. They had just finished a popping rendition of the Kingsmen's Louie Louie. The group's percussionist is about 70 years old, has a slick silvery ponytail, and speaks in easy, warm quips. He kept time with a pair of red castanets throughout the entire set, not missing a single beat. This man has rhythm.

Imagine my surprise, then, when he shared that he's also an arrhythmia patient, being treated for his atrial fibrillation at the Veteran's hospital. When I asked if his irregularly irregular heart rhythm has ever affected his ability to keep tempo, he replied wryly: "No way. I'm aging like a fine French wine."

In fact, some experts believe there is an intimate connection between musical composition and heart disease. In 2014, a team of musicologists and cardiologists observed that Ludwig van Beethoven's work has an arrhythmic quality that mimics heart disease.¹

One pianist went so far as to write that one wistful movement of Beethoven's String Quartet in B-flat Major reminds him of the sensation of shortness of breath and squeezing of the chest. Beethoven was not in good health, and, while it is only speculation, he may have suffered from arrhythmia or even angina.

A century later, Gustav Mahler's Ninth Symphony begins very slowly and steadily before it alternates between violent, off-tone movements and lovely, serene moments. It's been suggested by famous composer Leonard Bernstein (recently portrayed by Bradley Cooper in the Academy Award nominated film Maestro) that the sound of Mahler's own heart beat may have been an inspiration for the symphony's chaotic rhythm.²

One movement begins with the intoning of a single note with string instruments. Every other note is followed by a brassy flourish. If you listen carefully, the pattern sounds a bit like a diastolic murmur. Indeed, in 1911, Mahler was diagnosed with endocarditis by New York physician Emmanuel Libman, MD.³

Based on Libman's records, some medical historians suspect Mahler was afflicted with rheumatic mitral stenosis, which could have led to atrial fibrillation and such a whooshing diastolic murmur. Libman also made a name for himself in his own right: he is the namesake of Libman-Sacks endocarditis.

Could musical stylings be a symptom? It would not be the only way in which a deep connection to music could sharpen your diagnostic acumen. During my residency training, an attending cardiologist explained to his trainees that he auscultates the human heart the same way he listens to his son, an accomplished classical musician, perform in a symphony: quiet the mind, train the focus, and listen to each heart sound as if trying to pick out a single violin out of an orchestra. Try it sometime – what you discover may surprise you.

Music not only may have diagnostic value, but therapeutic value too, with music as therapy dating back to Pythagoras, who deduced that harmonizing sounds could harmonize the troubled mind.⁴ Around 2,500 years later, a randomized controlled trial suggested that listening to compositions by Mozart or Johannes Strauss Jr. for 35 minutes acutely lowered blood pressure and heart rate compared with sitting in silence.⁵

Listening to ABBA's greatest hits, in contrast, did not have any measurable effect. "Do you hear the drums, Fernando?" Perhaps Fernando should listen to Mozart's Symphony No. 40 instead. Even today, the effects of music on patients after a myocardial infarction or cardiac surgery are areas of active study.

So, there may be benefits to music. But what are the risks? The influential Cubano Miguelito Valdés was such an impassioned performer that he died of a heart attack while on stage in the Hotel Taquendama in Bogota, Colombia in 1978. He is still regarded as a pioneer of sonero music, a fast-paced blending of African and Cuban traditions which lives on in today's pop music.

A mordant 1999 report in the British Medical Journal observed that, amongst 20th century jazz musicians, playing the saxophone was associated with earlier mortality when compared with other instruments.⁶ The authors theorized that increased thoracic pressure while blowing a horn may pose a risk of reduced cerebral perfusion or cerebral embolism of blood clots. It's not for nothing that jazz notation refers to off-beat notes as syncopations, a cousin of the diagnostic term syncope.

Interestingly, this hazard was only observed in musicians who exclusively played the saxophone; musicians who played the sax plus another instrument seemed to be spared. Hence the report's tongue-in-cheek conclusion: if you're a jazz saxophonist, picking up a second instrument could have a mortality benefit. And it's presumably much more fun than taking antiplatelet therapy.

Perhaps, then, there is a case to make for including a "musical history" in your next assessment of a patient. At the very least, you have a wonderful excuse to explore great music – it may just make you a better physician. As the ponytailed percussionist at the Veteran's hospital is fond of saying: "Rock on."

This article was authored by Robert Milford Tungate, MD, Chief Fellow, Cardiovascular Disease, at the University of California, Irvine, and member of the Fellows in Training Member Section. Click here to join your Member Section.

References

1. Goldberger ZD, Whiting SM, Howell JD. The heartfelt music of Ludwig van Beethoven. Perspect Biol Med 2014;57:285-94.
2. Amenta C. The opening of the Mahler ninth symphony and the Bernstein "heart-beat" hypothesis. Naturlaut 2005;4:17-18.
3. Tofield A. Gustav Mahler's 'Maladie Célèbre'. Eur Heart J 2019;40:3134-5.
4. Montinari MR, Giardina S, Minelli P, Minelli S. History of music therapy and its contemporary applications in cardiovascular diseases. South Med J Feb 2018;111:98-102.
5. Trappe HJ, Voit G. The Cardiovascular effect of musical genres. Dtsch Arztebl Int 2016;113:347-52.
6. Kinra S, Okasha M. Unsafe sax: cohort study of the impact of too much sax on the mortality of famous jazz musicians. BMJ 1999;319(7225):1612-3.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Cardiology Magazine, ACC Publications, Music, Myocardial Infarction, Cardiac Surgical Procedures