Introduction

About one in every three U.S. adults does not engage in leisure-time physical activity, and physical inactivity is the fourth leading risk factor for global death, responsible for 1 to 2 million deaths annually (Collaborators GBDRF et al., 2015). Regular exercise is associated with lower cardiovascular and all-cause mortality, among other health benefits, such as reduced incidence of diabetes and greater cancer prevention (McKinney et al., 2016). Most U.S. adults do not meet guideline recommendations for regular physical activity, which include at least 150 minutes per week of moderate-intensity exercise or 75 minutes per week of vigorous exercise, or an equivalent combination of both. Older adults in the United States are even less likely to meet physical activity guidelines for a variety of reasons, often related to a higher burden of comorbidities that may limit participation in physical exercise (Elgaddal & Kramarow, 2024). Singing is a physical activity, though perhaps with less reliance on skeletal muscle. Therefore, could singing, similar to traditional physical exercise, lower cardiovascular disease burden and mortality?

Vascular endothelial cell function is an important predictor of cardiovascular health (Matsuzawa et al., 2015). The vascular endothelial cells are a monolayer of cells lining the inside of our blood vessels and inside of our heart. These cells have many important physiological roles in maintaining homeostasis, including production of nitric oxide (NO), a vasodilator that impacts blood pressure and flow, and preventing thrombosis (clot formation) in blood vessels. When this important layer of cells is compromised (hypertension, unhealthy diet, high cholesterol, etc.), the process of atherosclerosis ensues and can progress over time. Vascular endothelial function can be measured noninvasively and has become an important tool and biomarker in cardiovascular research to test the impact of interventions on endothelial cell function (Man et al., 2020). For example, we know that acute bouts of exercise improve vascular endothelial function, whereas smoking and high saturated fat diets are detrimental to endothelial cell function (Higashi, 2023; Man et al., 2020).

Singing and Vascular Function

Beginning in 2017, my research team set out to examine the effects of singing on vascular function. Because I am not a singer or musician myself, I teamed up with music professors and music therapy experts to conduct this research. Initially, we enrolled all-comers visiting our outpatient cardiology clinics. We found that singing for just 14 minutes led to improvements in microvascular endothelial function (Somayaji et al., 2022). The positive changes were most impressive in subjects with abnormal baseline endothelial function. This would include patients with atherosclerotic cardiovascular disease (coronary artery disease, which includes history of myocardial infarction, percutaneous coronary angioplasty or coronary stent, or coronary arterial bypass grafting, and peripheral arterial disease). Therefore, in our larger clinical trial, which was a randomized crossover control design, we focused on enrolling older patients with known coronary artery disease (Bagherimohamadipour et al., 2024). This clinical trial was funded by the National Center for Complementary and Integrative Health of the National Institutes of Health following a strategic initiative with funding announcements to increase research on the intersections of music and health. I am very excited to be able to share the main results and findings from this study, which were recently published (see Figure 1).

The Framingham Reactive Hyperemia Index (fRHI) is a clinical metric derived from the landmark Framingham Heart Study used to evaluate microvascular and endothelial health. It measures how effectively your blood vessels dilate in response to temporary blood flow restriction, helping scientists identify early signs of cardiovascular disease. We found that singing for 30 minutes to an instructional video created by a voice professor led to improvement in microvascular endothelial function, as measured by the fRHI, when compared to a control visit (during which participants underwent the same set of tests in the same environment but underwent a hearing test instead of the singing intervention). There was no significant change in macrovascular (large artery) function. The microcirculation, constituted by pre-arterioles, arterioles, capillaries, and venules, is responsible for most of the resistance to flow that modulates blood pressure and tissue perfusion and has increasingly been recognized as a key feature of cardiovascular disease compared to the larger, “macro” vasculature (Masi et al., 2021). Most importantly, the improvement in vascular function in our study translates into a 25% reduction in cardiovascular risk, which is similar to participation in a traditional cardiac rehabilitation program (Lanza et al., 2020).

We also measured heart rate variability (HRV), which reflects autonomic nervous system balance – or the balance between our parasympathetic (“rest and digest”) and sympathetic (“fight or flight”) nervous systems. Some of the reductions in HRV we observed were similar to those seen with light-intensity physical exercise (Bagherimohamadipour et al., 2025). Therefore, we conclude that the cardiovascular benefits of singing overlap with those of traditional physical exercise.

An interesting and noteworthy finding was that we observed a carryover effect on vascular function with the singing interventions. This likely means that a minimum of two days (range 2–7 days between visits) for potential washout from the previous visit was not long enough. One possible explanation for this carryover effect is the “earworm”—the experience of a song that repeats persistently in the mind—is a ubiquitous yet mysterious cognitive phenomenon, manifested as “inner singing” and may result in continued singing after the intervention. We did not ask subjects if they continued to sing in the days following their interventions, but this would be important to consider in future studies. This provides some proof of concept on the potential for earworms to have a real physiological effect, but more definitive studies are needed.

Next Steps

Natural next steps are to evaluate the chronic vascular adaptation to a longer (several weeks) singing intervention, and this is exactly what our team is preparing to do. We are designing a virtual solo-singing video series with a variety of songs from different genres, that participants can do from their own homes over twelve weeks. If successful, this would be straightforward to implement on a larger scale. Even though patients would need to complete the intervention independently, we plan to incorporate automated reminders and due dates to complete the assigned singing. We also recognize the potential benefits, such as improved well-being, of group singing intervention (Campbell et al., 2022). At this time, we are planning for informal singing groups without specific roles (soprano, alto, tenor, bass, etc.) to increase engagement from those who may not have singing experience, but it is important to consider if more formal choral singing instruction would yield different results. Older adults in the United States are often plagued with social isolation and loneliness as friends and loved ones in their age group pass away. Perhaps group singing with others in the same age group could mitigate this loneliness and lead to additional benefits, including improved quality of life. Therefore, we are also preparing to design a group singing intervention for this purpose. Long term, group singing could potentially be integrated into cardiac rehabilitation as an alternative or as a supplement to the traditional exercise component of these important rehabilitation programs.

Summary

The benefits of singing for cardiac patients are both exciting and promising. Our study showed that singing can reduce the risk of clinical cardiovascular events by as much as 25% and may offer treatment opportunities for individuals who face challenges engaging in traditional physical exercise. Future research should investigate optimal singing intervention dosage as well as the comparative benefits of individual and group singing programs.

References

Bagherimohamadipour, M., Hammad, M., Visotcky, A., Sparapani, R., & Kulinski, J. (2024). Effects of singing on vascular health in older adults with coronary artery disease: A randomized trial. medRxiv. https://doi.org/10.1101/2024.07.25.24311033

Bagherimohamadipour, M., Hammad, M., Visotcky, A., Sparapani, R., & Kulinski, J. (2025). Effects of singing on vascular health in older adults with coronary artery disease: A randomized, crossover trial. Frontiers in Cardiovascular Medicine, 12, 1546462. https://doi.org/10.3389/fcvm.2025.1546462

Campbell, Q., Bodkin-Allen, S., & Swain, N. (2022). Group singing improves both physical and psychological wellbeing in people with and without chronic health conditions: A narrative review. Journal of Health Psychology, 27(8), 1897–1912. https://doi.org/10.1177/13591053211012778

Collaborators GBDRF, Forouzanfar, M. H., Alexander, L., et al. (2015). Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 386(10010), 2287–2323. https://doi.org/10.1016/S0140-6736(15)00128-2

Elgaddal, N., & Kramarow, E. A. (2024). Characteristics of older adults who met federal physical activity guidelines for Americans: United States, 2022 (National Health Statistics Report No. 215). https://doi.org/10.15620/cdc/166708

Higashi, Y. (2023). Smoking cessation and vascular endothelial function. Hypertension Research, 46(12), 2670–2678. https://doi.org/10.1038/s41440-023-01455-z

Killingly, C., & Lacherez, P. (2023). The song that never ends: The effect of repeated exposure on the development of an earworm. Quarterly Journal of Experimental Psychology, 76(11), 2535–2545. https://doi.org/10.1177/17470218231152368

Lanza, G. A., Golino, M., Villano, A., et al. (2020). Cardiac rehabilitation and endothelial function. Journal of Clinical Medicine, 9(8), 2487. https://doi.org/10.3390/jcm9082487

Man, A. W. C., Li, H., & Xia, N. (2020). Impact of lifestyles (diet and exercise) on vascular health: Oxidative stress and endothelial function. Oxidative Medicine and Cellular Longevity, 2020, 1496462. https://doi.org/10.1155/2020/1496462

Masi, S., Rizzoni, D., Taddei, S., et al. (2021). Assessment and pathophysiology of microvascular disease: Recent progress and clinical implications. European Heart Journal, 42(26), 2590–2604. https://doi.org/10.1093/eurheartj/ehaa857

Matsuzawa, Y., Kwon, T. G., Lennon, R. J., Lerman, L. O., & Lerman, A. (2015). Prognostic value of flow-mediated vasodilation in brachial artery and fingertip artery for cardiovascular events: A systematic review and meta-analysis. Journal of the American Heart Association, 4(11). https://doi.org/10.1161/JAHA.115.002270

McKinney, J., Lithwick, D., Morrison, B., et al. (2016). The health benefits of physical activity and cardiorespiratory fitness. BCMJ, 58(3), 131–137.

Somayaji, K., Frenkel, M., Tabaza, L., et al. (2022). Acute effects of singing on cardiovascular biomarkers. Frontiers in Cardiovascular Medicine, 9, 869104. https://doi.org/10.3389/fcvm.2022.869104

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