Effect of Acupressure on Pain Severity and Vital Signs in Coronary Artery Disease: A Systematic Review and Meta-Analysis

Abstract

Introduction

Pain, a common symptom of coronary artery disease (CAD), changes physiological parameters, which can aggravate ischemia and increase cardiac workload. Acupressure, as a complementary therapy, can be beneficial by relieving pain and modulating vital signs. This systematic review and meta-analysis aimed to determine the effect of acupressure on pain severity and physiological parameters in patients with CAD.

Methods

A systematic search of randomized controlled trials in PubMed, Embase, Web of Science, Scopus, and Cochrane databases was conducted to investigate the effect of acupressure on pain and vital signs in adult CAD patients, following the PRISMA-2020 guideline. The quality assessment of the included studies was conducted using the RoB-2. A DerSimonian and Laird random effects model was undertaken using Stata-17.0 software.

Results

A total of 9 studies (857 patients) were included in the meta-analysis. At the time of measuring the results immediately after the intervention, acupressure had a statistically significant effect on reducing systolic blood pressure (SBP), heart rate (HR), and pain severity, with the mean difference of MD=-3.66, 95% CI (-5.44, -1.87) and MD=-2.46, 95% CI (-3.29, -1.64) and MD=-0.24, 95% CI (-0.42, -0.07) respectively. However, the results of diastolic blood pressure (DBP) and respiratory rate (RR) measurements were not significantly different. HR was also measured 30 minutes after the intervention in two studies. Based on the meta-analysis, acupressure did not significantly reduce HR 30 minutes after the intervention.

Conclusion

Acupressure can be a useful, non-pharmacological, and simple method in short-term reducing of pain severity, HR, and SBP, along with pharmacological management. However, the overall certainty of evidence and number of included studies are low, indicating a need for further high-quality research for a more certain conclusion.

Keywords

acupoint pain hemodynamic parameters coronary angiography myocardial ischemia

1. Introduction

Coronary artery disease (CAD), caused by atherosclerosis in the coronary arteries, narrows them and reduces blood flow to the heart. It is the world’s leading cause of death and the most common cardiovascular disease in adults. CAD can also result in chronic or permanent disability, significantly impacting populations in developing nations (Hinkle J et al., 2022; Locsalzo J et al., 2022; Ralapanawa & Sivakanesan, 2021).

CAD progression can lead to stable angina or acute coronary syndrome, including unstable angina and myocardial infarction (Locsalzo J et al., 2022). Pain is a key symptom in both, ranging from mild to severe, though it may be atypical in elderly or diabetic patients. This pain can also stem from procedures like angiography or bypass surgery (de Souza Brito F et al., 2017; Vagharseyyedin SA et al., 2022). Regardless of its origin, uncontrolled pain in these patients can increase cardiac workload and exacerbate myocardial blood supply issues (Hinkle J et al., 2022).

Pain can increase heart rate, respiratory rate, blood pressure, and the heart’s oxygen demand, which can lead to complications, a faster ischemic process, and a longer hospital stay (Düzel B et al., 2023). In addition, patient anxiety during ischemic attacks and invasive procedures can cause instability in physiological and hemodynamic parameters (Hinkle J et al., 2022; Locsalzo J et al., 2022). Consequently, a key treatment goal is stabilizing these parameters, requiring both pharmacological and non-pharmacological interventions to address root causes like pain (Batvani M et al., 2018).

Despite established pain management guidelines, inadequate pain relief remains a global issue (Sedighie L et al., 2020). While pharmacological methods are common, combining them with non-pharmacological approaches, such as acupressure, offers significant benefits. These include reduced medication use, better pain relief, higher patient satisfaction, and fewer side effects (Kia Z et al., 2021). Nurses play a vital role in administering these non-pharmacological methods, one of which is acupressure (Berman et al., 2020; Herdman et al., 2021).

Acupressure is a complementary therapy originating from Traditional Chinese Medicine. It involves applying pressure to specific body points (acupoints) with fingers or tools to restore the balance of vital energy (Qi) flowing through meridians, thereby producing therapeutic effects (Lindquist R et al., 2022; Rahimi H et al., 2020).

The body has 12 primary and 8 extraordinary meridian channels. A disruption or deficiency in the flow of Qi through these pathways can cause illness and pain. There are 365 acupoints along these meridians, each linked to specific areas of the body. Applying pressure to these points yields targeted effects, making pain relief one of acupressure’s most frequent uses (Kwon & Lee, 2018; Lindquist R et al., 2022).

The exact mechanism by which acupressure alleviates pain remains unclear. One proposed theory is the gate control theory of pain. According to this theory, the stimulation of thick nerve fibers such as A-beta and A-alpha inhibits the transmission of pain messages to the brain, resulting in the absence of pain (Audette & Bailey, 2008). Acupressure, through stimulation of acupoints, activates thick nerve fibers and reduces pain (Rahimi H et al., 2020).

Some other suggested mechanisms for pain relief by acupressure include (1) local effects and immediate suppression of pain transmission; (2) stimulation of endorphin release; (3) stimulation of immune system cells to invade affected areas; and (4) enhancement of the body’s opioid system (Herdman et al., 2021). Furthermore, numerous studies demonstrate that stimulating acupoints can regulate and modify autonomic nervous system function by enhancing parasympathetic tone and suppressing sympathetic activity. Consequently, blood pressure, heart rate, and respiratory rate decrease. Thus, adjusting hemodynamic and physiological variables is another application of acupressure (McFadden & Hernández, 2010).

1.1. Review of Literature

Several previous studies have shown that acupressure has a positive effect in reducing pain severity or adjusting vital signs. For example, several studies have demonstrated that acupressure can reduce labor pain (Chen et al., 2021; Xu et al., 2023), abdominal pain (Basuony et al., 2022; Rajai et al., 2025), musculoskeletal pain (Lee et al., 2025), and other types of pain. In terms of vital signs modulation, acupressure has a significant impact on blood pressure (Restawan et al., 2023) and heart rate (Ceyhan et al., 2019; Wiyatno et al., 2017) according to previous studies.

Despite the importance of pain relief and the adjustment of physiological and hemodynamic variables in patients with CAD, and the potential of acupressure as a simple and low-risk non-pharmacological method along with pharmacological interventions, it is thought that there has been limited research on the effectiveness of acupressure in relieving pain and modulating vital signs in CAD patients, and to our knowledge, no prior systematic reviews on this specific topic exist. Hence, this study aimed to systematically review the literature to determine if acupressure can effectively alleviate pain and stabilize vital signs in patients with CAD.

2. Methods

This study was conducted to perform a systematic review and meta-analysis. A search of reliable databases was conducted to identify published articles on the effects of acupressure on pain intensity and vital signs in patients with coronary artery disease. The systematic review was conducted and reported according to the PRISMA 2020 Statement (Figure 1) (Page MJ et al., 2021).

Figure 1.

Flowchart of study search and selection process based on PRISMA-2020 statement

2.1. Information Sources and Search Strategy

A systematic search of English-language articles published up to August 20, 2024, was conducted in the PubMed, Embase, Web of Science, Scopus, and Cochrane databases. Appropriate keywords were extracted using MeSH and EMTREE. Then, a systematic search was performed based on the following query (see Appendix).

Acupressure, Pain, Pain measurement, Acute pain, Vital signs, Blood pressure, Heart rate, Respiratory rate, Hemodynamics, Hemodynamic Monitoring, Physiologic Monitoring, Coronary Artery Disease, Myocardial Ischemia, Myocardial Infarction, Coronary Disease, Acute Coronary Syndrome, Coronary Artery Bypass, Percutaneous Coronary Intervention, Angioplasty, Cardiac Catheterization, Coronary Stenosis, Coronary Angiography.

2.2. Inclusion and Exclusion Criteria

The inclusion criteria are as follows: (1) Articles must report on randomized controlled trials (RCTs). (2) The RCTs must involve adult patients with coronary artery disease (CAD), regardless of gender. (3) The acupressure technique used must be non-invasive. (4) The patients in the selected studies must be undergoing angiography, angioplasty, or coronary artery bypass grafting. (5) Each study must include at least one group where acupressure is applied as a standalone intervention.

The exclusion criteria were as follows: (1) The article is a case report or review; (2) acupressure was combined with other complementary or alternative medicine therapies in a treatment group; (3) acupressure was administered using invasive methods or electrical stimulation; (4) the measured pain was a direct result of drain or catheter removal following an invasive CAD procedure; and (5) for patients undergoing angiography or coronary artery bypass grafting (CABG), acupressure was applied only before the primary procedure.

2.3. Selection of Studies and Data Extraction

After a systematic search of the databases, duplicate records were removed using EndNote 21 software. Two authors then independently screened the remaining articles following the PRISMA 2020 guidelines (Page MJ et al., 2021). Screening involved two phases: during the title and abstract review, inclusion criteria 1 and 2 and exclusion criterion 1 were applied; during the full-text review, all inclusion and exclusion criteria were assessed. To ensure consistent application of the criteria, the reviewers first conducted a pilot test on 10 randomly selected studies. Any disagreements between reviewers during screening or data extraction were resolved through a structured process: an initial discussion was held to seek consensus, followed, if needed, by escalation to a senior author for a final, blinded decision. This process ensured the objective and consistent resolution of all discrepancies (Figure 1).

Relevant studies were selected, and the necessary information was extracted. This included the study objectives, methodology, study groups and their related interventions, acupoints used and their locations, and primary outcomes (e.g., effect of acupressure on pain severity, blood pressure, and heart and respiratory rates) (Table 1). The data extraction form was piloted in 3 studies, and after finalization, was applied to all included articles.

Table 1.

Characteristics and Main Outcomes of Included Studies

Authors; country; year	Aim	Methodology:1. Design2. Sample size (per groups)3. Blinding	Intervention group(s)	Control group and/or Sham group	Acupoints location	Primary outcomes
Narimani et al; Iran; 2018 ²¹	To evaluate the effect of acupressure on pain severity in patients undergoing coronary artery graft admitted to a coronary care unit.	1. RCT 2. 70 (35/35) 3. Double-blind	Bilateral pressure was applied on the organs at the LI4 point for 20 minutes in 10-second pressure and 2-second resting periods. The applied pressure was about 3-5 kg such that the patient could.	Sham group: Touching without pressure in the same pattern and at the same point as the intervention group.	Hand (LI4)	In the Intervention group, pain severity was significantly reduced after CABG. Also, the frequency of opioid and non-opioid analgesics was lower in this group.
Rahmani et al; Iran; 2019 ²⁵	To compare hand reflexology versus acupressure on anxiety and vital signs in female patients with coronary artery diseases.	1. RCT 2. 135 (45/45/45) 3. Double-blind	Acupressure Group: Acupressure on PC6, 10 min per each hand. Hand Reflexology Group: 10-minute Massage on three reflexology points for the solar plexus, pituitary gland, and heart with moderate pressure on each hand (2 min for each point).	Sham group: Conditions similar to the intervention groups were created, but a touch on thumbs without the stimulation of hand reflexology or acupressure was applied.	Forearm (PC6)	Acupressure and hand reflexology did not affect HR, RR, and MAP^e. Only anxiety was reduced in intervention groups.
Bal & Gun; Cyprus; 2024 ²²	To analyze the effects of acupressure on pain, anxiety, and vital signs in patients who underwent coronary angiography.	1. RCT 2. 105 (35/35/35) 3. Single-blind	Received acupressure on the heart meridian 7 (HT7), large intestine meridian 4 (LI4), and pericardium meridian (PC6) acupoints 30 min after admission to the clinic, for 16 minutes.	Control group: Usual care Sham group: Acupressure on locations 1–1.5 cm away from intervention points	Hand (LI4); Wrist (HT7); Forearm (PC6)	Acupressure reduced state anxiety, pain, mean BP, HR, and RR in the intervention and sham groups.
Sajadi et al; Iran; 2023 ²³	To determine the effect of auriculotherapy on physiological parameters and anxiety of male patients undergoing coronary angiography	1. RCT 2. 94 (47/47) 3. Single-blind	Acupressure at four ear points (each point for 1 min) counterclockwise with the thumb 60 minutes before the angiography. The four ear acupoints include Shenmen, Relaxation, Tranquilizer, and Endocrine on the non-dominant side.	Sham group: Acupressure was performed by the same researcher at a sham point for the same period, except 4 points non-related to anxiety and further away from the main points.	Ear (Shenmen, Relaxation, Tranquilizer, Endocrine points)	Acupressure significantly reduced SBP, DBP, HR, and RR in patients of the intervention group.
Batvani et al; Iran; 2018 ⁷	To evaluate the effectiveness of acupressure on the physiological parameters of patients with myocardial infarction.	1. RCT 2. 64 (32/32) 3. Single-blind	The acupressure points that were used in this study were HT7, PC6, PC7, LI4, and LV3. Acupressure in five points and at any point for 2 minutes, twice a day, for 3 days.	Sham group: False points about 1 cm away from real points were pressured for 2 minutes.	Forearm (PC6); Wrist (HT7, PC7); Hand (LI4); Foot (LV3) .	In the Intervention group: Mean systolic blood pressure was reduced; arterial oxygen saturation was significantly higher than the control group.
Rezvani et al; Iran; 2022 ²⁰	To evaluate the effect of acupressure on low back pain and fatigue after coronary angioplasty through the femoral artery.	1. RCT 2. 75 (25/25/25) 3. Single-blind	Acupressure was applied to four points, including ST36, GV26, SI3, and BL60, each for two minutes, at two, four, six, and eight hours after angioplasty.	Sham group: All measures performed in the experimental group were done without putting pressure.	Leg (ST36); Upper lip (GV26); Hand (SI3); Foot (BL60).	Acupressure reduced the severity of low back pain and fatigue in the intervention group.
Düzel et al; Turkey; 2023 ⁶	To determine the effect of acupressure on pain level and hemodynamic parameters in patients undergoing coronary angiography.	1. RCT 2. 124 (62/62) 3. None	Acupressure on the LI4, PC6, and LI11 points for 15 min 2 hours after coronary angiography.	Control group: Usual care	Hand (LI4); Forearm (PC6); Elbow (LI11).	Acupressure reduced pain severity but did not affect SBP, HR, and oxygen saturation. However, the DBP and RR were higher in the intervention group.
Nadali et al; Iran; 2024 ²⁴	To investigate the effect of acupressure on vital signs, comfort, and psychological distress in patients undergoing coronary angiography	1. RCT 2. 70 (35/35) 3. None	Acupressure on EX-HN3 during two 10-minute sessions, with an average frequency of 20–25 times per minute.	Control group: Usual care	Head (EX-HN3).	Acupressure significantly reduced SBP, DBP, HR, and RR in patients of the intervention group.
Vagharseyyedin et al; Iran; 2022 ⁴	To Investigate the effect of ear acupressure on back pain reduction in patients after coronary angiography.	1. RCT 2. 117 (58/59) 3. None	The Shen Men, kidney, and spinal column points were gently pressed for 2 minutes (with a pressure of one kilogram) using an ear acupuncture pen. A 1-minute interval was considered between the pressings of each point. the intervention lasted 8 minutes for each ear.	Control group: Usual care	Ear (Shenmen, kidney, and spinal column points)	Acupressure significantly reduced back pain severity immediately and 2 hours after the intervention.

Abbreviations: Randomized Controlled Trial (RCT); Coronary Artery Bypass Grafting (CABG); Heart Rate (HR); Respiratory Rate (RR); Mean Arterial Pressure (MAP); Blood Pressure (BP); Systolic Blood Pressure (SBP); Diastolic Blood Pressure (DBP).

2.4. Critical Appraisal

The revised Cochrane Risk-of-Bias Tool for randomized trials (RoB 2) was used to evaluate and critically appraise the RCT studies. This tool assesses RCTs based on specific questions in five domains, including: (1) the risk of bias in the randomization process; (2) deviation from the intervention; (3) missing outcome data; (4) measurement of the outcome; and (5) selection of the reported result. The studies were subsequently classified based on their level of bias risk as “Low risk,” “High risk,” or “Some concerns” (Sterne et al., 2019). Figure 2 shows the results of the evaluation of RCT articles based on the Risk of Bias Visualization tool (ROBVIS) (McGuinness LA & Higgins JPT, 2021). Additionally, the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach (Schünemann et al., 2013). The evaluation and appraisal of the studies were conducted independently by three researchers. After sharing the results and resolving any conflicts, qualified studies were selected.

Figure 2.

Risk of bias assessment for included studies based on RoB-2

2.5. Data Analysis

Data on the outcomes (pain severity, systolic blood pressure, diastolic blood pressure, heart rate, and respiratory rate) were extracted from nine studies into an Excel file. These studies reported the mean and standard deviation for each outcome both before the intervention and at various post-intervention time points: immediately after, and at 10 minutes, 20 minutes, 30 minutes, 90 minutes, 2 hours, 4 hours, and 6 hours after the intervention.

Time points for which only a single study reported data for a given outcome (e.g., pain at 2 hours) were excluded from the meta-analysis. The mean difference and standard error for each outcome were calculated for each time interval relative to baseline. Studies reporting data at common time points were pooled for analysis at each respective interval.

As the control intervention differed between studies—with some using sham acupressure and others using standard care alone—two separate analyses were performed. The first compared the acupressure group to the sham acupressure group, and the second compared the acupressure group to the no-intervention (usual care only) group.

A fixed-effects model was applied when heterogeneity was low (I² <50%, p > 0.10). Due to the high heterogeneity observed across studies and patient populations, a DerSimonian and Laird random-effects model was ultimately employed for the analysis using Stata 17.0. This substantial heterogeneity was interpreted as reflecting meaningful differences in acupressure protocols, patient characteristics, and the timing of outcome measurements across studies. Consequently, pooled estimates were interpreted with caution, emphasizing overall trends rather than precise effect sizes. Statistical significance was determined when the 95% confidence interval of the pooled effect did not include the null value (α=0.05), as confidence intervals more effectively illustrate both the direction and the precision of the effect estimates.

The time of outcome measurement was the only variable suitable for subgroup analysis. In Table 2, the forest plots for each outcome are presented separately for the intervention versus sham groups and the intervention versus no-intervention groups. Given that the number of studies in each meta-analysis ranged from two to three, it was not possible to assess publication bias (Carlson et al., 2023; Sterne et al., 2011). The implications of the limited study count, substantial heterogeneity, and inability to formally evaluate publication bias are discussed further in the Limitations section.

Table 2.

Comparison of Acupressure With Sham Intervention and No Intervention Based on Pain Severity, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Heart Rate (HR), and Respiratory Rate (RR)

Outcomes	Comparison of the acupressure group with the sham intervention group	Comparison of the acupressure group with the intervention group
Pain severity
SBP
DBP
HR
RR

^aThe red diamond is the overall effect size.

^bTo better display each of the forest plots, the x-axis ranges have been adjusted to be appropriate for the results of that plot.

^cThe left side favors the acupressure intervention, and the right side favors the sham intervention or no intervention.

3. Results

The initial search yielded 85 articles. After removing duplicates, 35 remained. Of these, 26 were excluded for irrelevance, meeting exclusion criteria, or being only available as conference abstracts without full text. Nine articles were ultimately selected for inclusion (Figure 1). These were then assessed using the Revised Cochrane Risk-of-Bias Tool for Randomized Trials (Figure 2).

The nine included RCTs involved 857 patients. The studies focused on CAD patients in various settings: six during angiography/angioplasty, one during bypass surgery, one after myocardial infarction, and one in the CCU for chest pain. The primary intervention was acupressure, aimed at reducing pain and stabilizing vital signs, with some studies also measuring anxiety and fatigue. One trial combined acupressure with hand reflexology. The designs included double-blind, single-blind, and open-label RCTs.

Using acupressure at various body points in all these studies resulted in reduced pain intensity and adjusted vital signs in some of them. However, in some studies, acupressure did not affect vital signs. Also, most of the acupoints used in the studies were located in the hand, wrist, or forearm areas (Table 1).

Due to the lack of heterogeneity (I² < 50% and p-value > 0.10), a fixed-effect model was used to estimate the difference in the mean systolic blood pressure (SBP) outcome in the acupressure and sham intervention groups, and in other cases, the random-effect model was used (Table 2). In this section, the meta-analysis results are presented separately for each outcome and can be found in Table 2.

3.1. Pain Severity

To compare the two groups of acupressure and sham intervention, only two studies (Narimani M et al., 2018; Rezvani F et al., 2022) measured the pain intensity immediately after the intervention. The meta-analysis results indicated that acupressure significantly reduces pain intensity compared to not doing it, with a mean difference (MD) of -0.24, 95% CI (-0.42, -0.07).

To compare the acupressure and no intervention groups at two measurement times, immediately and 30 minutes post-intervention, three studies (Düzel B et al., 2023; Rezvani F et al., 2022; Vagharseyyedin SA et al., 2022), and two studies (Bal & Gun, 2024; Düzel B et al., 2023) measured pain levels, respectively. The results of the meta-analysis showed that acupressure significantly reduced pain intensity immediately after the intervention, with an MD of -0.90, 95% CI (-1.68, -0.12). However, 30 minutes after the intervention, there was no difference in pain intensity between the two groups.

3.2. Systolic Blood Pressure (SBP)

To compare the two groups of acupressure and sham intervention, only two studies (Batvani M et al., 2018; Sajadi SA et al., 2023) measured systolic blood pressure immediately after the intervention. The results of the meta-analysis showed that acupressure significantly reduced systolic blood pressure compared to sham intervention, with a mean difference MD = -3.66, 95% CI (-5.44, -1.87). To compare the two groups of acupressure and no intervention, two studies (Düzel B et al., 2023; Nadali J, 2024) measured SBP at two measurement times: immediately and 30 minutes after the intervention. The results of the meta-analysis showed that performing acupressure compared to not performing it on SBP, either immediately after the intervention or 30 minutes after the intervention, showed no difference between the two groups.

3.3. Diastolic Blood Pressure (DBP)

Only two studies (Batvani M et al., 2018; Sajadi SA et al., 2023) measured diastolic blood pressure immediately after the intervention, to compare the two groups of acupressure and sham intervention. The results indicated that doing acupressure compared to not doing it had a decreasing effect on diastolic blood pressure with a mean difference MD=-1.82, 95% CI (-3.83, 0.20), although this effect was not significant. For comparing the acupressure and no intervention groups at two measurement times, immediately and 30 minutes post-intervention, two studies (Düzel B et al., 2023; Nadali J, 2024) measured diastolic blood pressure. The meta-analysis found that acupressure did not have a significant effect on diastolic blood pressure at either time point.

3.4. Heart Rate (HR)

For comparing the acupressure and sham intervention groups at the time points immediately after and 30 minutes after the intervention, heart rate was measured in three studies (Batvani M et al., 2018; Rahmani Vasokolaei Z et al., 2019; Sajadi SA et al., 2023) and two studies (Bal & Gun, 2024; Batvani M et al., 2018) respectively. The meta-analysis results showed that acupressure significantly reduced heart rate immediately after the intervention, with an MD=-2.46, 95% CI (-3.29, -1.64), but had no significant effect at 30 minutes after the intervention. For comparing the acupressure and no intervention groups at two measurement times, heart rate was measured in two studies (Düzel B et al., 2023; Nadali J, 2024), and three studies (Bal SK & Gun M, 2024Bal & Gun, 2024; Düzel B et al., 2023; Nadali J, 2024) respectively. The meta-analysis showed that performing acupressure compared to not performing it on the heart rate either immediately after the intervention or 30 minutes later, there was no difference between the two groups.

3.5. Respiratory Rate (RR)

In the studies that measured the respiratory rate in the two groups of acupressure and sham intervention immediately after the intervention (Rahmani Vasokolaei Z et al., 2019; Sajadi SA et al., 2023), It was shown that acupressure had a decreasing effect on respiratory rate, with an MD=-0.49, 95% CI (-1.34, 0.36), though this effect was not significant. For comparing the acupressure and no intervention groups at two measurement times, respiratory rate was measured in two studies (Düzel B et al., 2023; Nadali J, 2024), and three studies (Bal & Gun, 2024; Düzel B et al., 2023; Nadali J, 2024) respectively. The meta-analysis revealed no significant effect of acupressure on respiratory rate at either time point.

3.6. Risk of Bias and Certainty of Evidence Assessment

All studies had been evaluated as some concern because of bias in the selection of reported results (dimension 5, Figure 2). Regarding other dimensions (bias due to randomization, deviations from intended intervention, missing data, and outcome measurement), all studies had a low risk of bias. Based on the GRADE assessment (Table 3), the certainty of evidence for all outcomes was rated as low or very low, primarily due to imprecision, risk of bias, and inconsistency (heterogeneity). The only exception was systolic blood pressure (SBP) in the comparison between acupressure and sham intervention groups, for which the certainty of evidence was rated as moderate.

Table 3.

Summary of Findings; Acupressure Compared With Sham Intervention and No Intervention for Pain, SBP, DBP, Heart Rate, and Respiratory Rate

Intervention and comparison groups	Outcome (time frame)	Number of participants (studies)	Pooled effect size (95% CI)	Quality of the evidence (GRADE)^a	Comments
Acupressure and sham intervention groups	Pain (immediately after intervention)	120 (2)	-0.24 (-0.42 to -0.07)	⊕⊖⊖⊖	Downgraded 1 for risk of bias ^b, 1 for inconsistency (heterogeneity), and 1 for small sample size.
	Pain (immediately after intervention)	120 (2)	-0.24 (-0.42 to -0.07)	Very low
	SBP (immediately after intervention)	158 (2)	-3.66 (-5.44 to -1.87)	⊕⊕⊕⊖	Downgraded 1 for risk of bias.
	SBP (immediately after intervention)	158 (2)	-3.66 (-5.44 to -1.87)	Moderate	Downgraded 1 for risk of bias.
	DBP (immediately after intervention)	158 (2)	-1.82 (-3.83 to 0.20)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (CI crosses null).
	DBP (immediately after intervention)	158 (2)	-1.82 (-3.83 to 0.20)	Very low
	Heart rate (immediately after intervention)	248 (3)	-2.46 (3.29 to -1.64)	⊕⊕⊖⊖	Downgraded 1 for risk of bias, and 1 for inconsistency (heterogeneity).
	Heart rate (immediately after intervention)	248 (3)	-2.46 (3.29 to -1.64)	Low
	Heart rate (30 minutes after intervention)	134 (2)	0.15 (-8.97 to 9.26)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (wide CI) and small sample size.
	Heart rate (30 minutes after intervention)	134 (2)	0.15 (-8.97 to 9.26)	Very low
	Respiratory rate (immediately after intervention)	184 (2)	-0.49 (-1.34 to 0.36)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (CI includes no effect).
	Respiratory rate (immediately after intervention)	184 (2)	-0.49 (-1.34 to 0.36)	Very low
Acupressure and no intervention group	Pain (immediately after intervention)	291 (3)	-0.90 (-1.68 to -0.12)	⊕⊕⊖⊖	Downgraded 1 for risk of bias, and 1 for inconsistency (heterogeneity).
	Pain (immediately after intervention)	291 (3)	-0.90 (-1.68 to -0.12)	Low
	Pain (30 minutes after intervention)	194 (2)	-1.42 (-4.14 to 1.30)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for imprecision (wide CI, crosses null), and 1 for inconsistency (heterogeneity).
	Pain (30 minutes after intervention)	194 (2)	-1.42 (-4.14 to 1.30)	Very low
	SBP (immediately after intervention)	194 (2)	-3.37 (-14.82 to 7.37)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (very wide CI).
	SBP (immediately after intervention)	194 (2)	-3.37 (-14.82 to 7.37)	Very low
	SBP (30 minutes after intervention)	194 (2)	1.28 (-9.95 to 12.52)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (very wide CI).
	SBP (30 minutes after intervention)	194 (2)	1.28 (-9.95 to 12.52)	Very low
	DBP (immediately after intervention)	194 (2)	-0.96 (-5.97 to 4.02)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for imprecision (wide CI, crosses null), and 1 for inconsistency (heterogeneity).
	DBP (immediately after intervention)	194 (2)	-0.96 (-5.97 to 4.02)	Very low
	DBP (30 minutes after intervention)	194 (2)	2.12 (-5.47 to 9.72)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (very wide CI).
	DBP (30 minutes after intervention)	194 (2)	2.12 (-5.47 to 9.72)	Very low
	Heart rate (immediately after intervention)	194 (2)	-2.73 (-6.21 to 0.74)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (CI includes no effect).
	Heart rate (immediately after intervention)	194 (2)	-2.73 (-6.21 to 0.74)	Very low
	Heart rate (30 minutes after intervention)	194 (2)	-1.48 (-7.02 to 4.06)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (wide CI).
	Heart rate (30 minutes after intervention)	194 (2)	-1.48 (-7.02 to 4.06)	Very low
	Respiratory rate (immediately after intervention)	194 (2)	-0.24 (-1.90 to 1.43)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (wide CI).
	Respiratory rate (immediately after intervention)	194 (2)	-0.24 (-1.90 to 1.43)	Very low
	Respiratory rate (30 minutes after intervention)	264 (3)	-1.45 (-4.94 to 2.03)	⊕⊖⊖⊖	Downgraded 1 for risk of bias, 1 for inconsistency (heterogeneity), and 1 for imprecision (wide CI).
	Respiratory rate (30 minutes after intervention)	264 (3)	-1.45 (-4.94 to 2.03)	Very low

^aPublication bias criterion was not applicable because of the small number of studies (between 2-3 studies for each outcome).

^bAll studies had some concerns in risk of bias assessment.

4. Discussion

The results indicated that acupressure reduces pain intensity, HR, and SBP immediately after treatment in patients with CAD. It did not significantly affect their DBP and RR. Although some results are statistically significant, they do not always imply a clinically meaningful. These findings are preliminary and more robust research before strong clinical recommendations are needed. Thus, the interpretation of its clinical significance may be unclear.

Of course, if this simple and low-complication method is used in conjunction with pharmaceutical methods, better clinical results may be achieved. Additionally, more frequent acupressure applications, along with continuous monitoring of vital signs (e.g., 24-hour blood pressure monitoring), and studies with longer follow-up periods may better reveal clinical effects.

Several acupoints in different areas of the body can be used to relieve pain and regulate vital signs. PC6, HT7, and LI4 were used more (see Table 1). The PC6 acupoint on the wrist’s pericardium meridian is linked to cardiac function in ischemic heart disease (Feisong & Guozhong, 2020; Shi L et al., 2017). PC6 stimulation lowers heart rate and blood pressure by inhibiting sympathetic activity, thereby reducing myocardial oxygen demand. Research confirms its benefits, including a short-term increase in left ventricular ejection fraction and, after sustained stimulation, improvements such as a decreased pathological Q wave in ECG and reduced ischemic markers like Troponin-T, indicating better myocardial perfusion (Li H et al., 2019; Shi L et al., 2017; Wang S et al., 2015; Zheng HD et al., 2020).

HT7, located on the wrist’s heart meridian, addresses cardiac symptoms such as chest pain, palpitations, and irregular heartbeat (Feisong & Guozhong, 2020). Stimulating HT7 reduces heart rate by modulating the autonomic nervous system, likely due to the convergence of its spinal neurons (T1-T3) with cardiac nerves (Liang B et al., 2019; Son CG, 2019). LI4, situated between the first and second metacarpal bones, is widely used for its analgesic properties—particularly visceral and upper limb pain—by stimulating endorphin secretion from the hypothalamus (Düzel B et al., 2023; Feisong & Guozhong, 2020; Shi L et al., 2017).

While more RCTs are needed, these findings are supported by broader acupuncture research targeting the same points. For instance, a 2019 meta-analysis found acupuncture effective as a complementary angina treatment for CAD (Huang X et al., 2019), a conclusion echoed by another 2020 review (Wang JS et al., 2020). Also, a 2022 analysis showed that acupressure significantly reduced pain and opioid consumption after cardiac surgery (Liu M et al., 2022). Considering the effects of stimulating acupoints, especially PC6, on improving coronary blood supply, acupressure may also be effective in reducing cardiac pain; However, further studies are needed (Li H et al., 2019; Shi L et al., 2017; Wang S et al., 2015; Zheng HD et al., 2020).

According to the current study, acupressure can have a short-term reducing effect on SBP. This aligns with a 2020 systematic review, which concluded that auricular acupressure reduces both SBP and DBP in hypertensive patients (Zhao ZH et al., 2020). A 2020 review further concluded that combining auricular acupressure with medication is more effective for blood pressure control than drugs alone (Gao J et al., 2020). Other analyses support these findings, showing that acupuncture significantly lowers SBP in elderly patients (Wang T et al., 2023), and improves BP control in patients with grade 1 hypertension (Zhang M et al., 2022).

Due to the small number of included studies, it is not possible to clearly explain why acupressure did not significantly affect DBP in the current study’s findings. To address this, more robust RCTs in this field are needed. However, the differential effect on SBP versus DBP may point to acupressure’s primary mechanism. SBP is more responsive to changes in cardiac output and sympathetic activity, which acupressure (particularly at PC6 and HT7) likely modulates. DBP, however, is largely determined by peripheral vascular resistance, which may require longer or more intensive acupressure protocols to change (Khan I et al., 2024; Li H et al., 2019; Son CG, 2019).

This study found that acupressure effectively reduces heart rate in CAD patients. Supporting this, other reviews indicate that stimulating ear acupoints lowers heart rate (Hua K et al., 2023). Also, acupressure alleviates anxiety symptoms, including tachycardia, in patients undergoing surgery (Xie W et al., 2023). A 2018 systematic review concluded that combining acupuncture with antiarrhythmic drugs is more effective for controlling arrhythmias, such as atrial fibrillation and premature ventricular contractions, than medication alone (Liu J et al., 2018). Since the effects of acupressure on HR were short-lived, based on the results of the present study, it seems that more frequent application of acupressure is needed. However, given the limited number of included studies, this conclusion requires further studies.

The current analysis concluded that acupressure did not significantly affect respiratory rate, but this finding is limited by the small number (five) of included studies, indicating a need for more high-quality RCTs. In its justification, respiratory rate is primarily controlled by the brainstem’s tightly regulated chemoreflex loops, which respond to blood gas levels (Hall JE et al., 2021). While acupressure can promote relaxation, its effects appear stronger in modulating the autonomic nervous system (influencing metrics like blood pressure and heart rate) than in directly overriding the brainstem’s metabolic control of breathing. Similarly, a 2023 review found that stimulating auricular acupoints did not significantly affect oxygen saturation, though it was also based on limited evidence (Hua K et al., 2023). A meta-analysis by Yu et al. (2024), however, suggested that acupuncture might effectively alleviate dyspnea in patients with chronic respiratory conditions (Yu et al., 2024).

5. Strengths and Limitations

This study has several notable strengths. Primarily, it addresses a significant gap in evidence-based practice by rigorously evaluating the effects of acupressure as a complementary therapy for patients with CAD. By focusing on both objective clinical outcomes (vital signs) and patient-reported pain severity, the research provides a holistic assessment of the intervention’s efficacy. Furthermore, it is conducted from a distinct nursing perspective, thereby directly contributing to the body of knowledge for frontline cardiovascular care providers and offering practical insights that can be integrated into nursing care plans to improve patient comfort and outcomes.

This review has several key limitations. The small number of included studies (n=9) and meta-analyses with few trials severely limit statistical power and the precision of heterogeneity estimates, potentially leading to unreliable confidence intervals. The limited data also preclude a reliable assessment of publication bias.

Substantial heterogeneity was observed, stemming from variations in acupressure protocols (e.g., the specific acupoints chosen, duration of application, pressure intensity, and timing), patient characteristics, and outcome measurements. They are likely major determinants of the intervention’s efficacy. Subgroup analysis was not feasible due to the limited data, necessitating a narrative synthesis. These factors may explain the variability in effects and limit the generalizability of the findings. Future studies with standardized protocols and measures are needed for more robust analysis.

A pre-specified conservative analytical rule was applied: fixed-effect models were used for low heterogeneity (I² < 50%, Qp > 0.10), otherwise random-effects models were used. Despite the potential robustness of methods like Artung-Knapp-Sidik-Jonkman to heterogeneity variance changes, their potential for counterintuitive results led to a cautious approach (Langan et al., 2019). All pooled estimates were interpreted conservatively, avoiding over-interpretation where data were sparse, and emphasizing the need for further trials to enable more robust synthesis and advanced methods.

Assessment of publication bias was limited by the small number of studies in each pooled analysis (two to three per outcome). Following established guidance (Carlson et al., 2023; Sterne et al., 2011), visual or statistical methods for detecting small-study effects—such as funnel plots or Egger’s regression—were not applied, as these approaches are unreliable with fewer than ten studies. Consequently, while no formal or visual assessment of publication bias was conducted, the possibility of selective publication or reporting bias cannot be excluded and should be considered when interpreting the findings.

A further limitation is that only English-language articles were included. This decision was made to ensure direct accessibility and avoid potential ambiguities in translating articles from languages such as Chinese or Korean, which could have affected the results. These limitations may influence the meta-analytic findings and the reliability of the conclusions.

6. Implications for Nursing Practice

Considering the results of this and other similar studies, it can be suggested that acupressure be included in the nursing care plan of CAD patients and can help empower them in self-care after sufficient training. However, because of its short-term effects, it should be performed continuously and frequently in conjunction with, not a replacement for, standard pharmacological and non-pharmacological treatments. However, all these suggestions are subject to proper training, competency assessment for nurses, and consideration of patient safety. More high-quality studies are also recommended to investigate the effects of acupressure on CAD patients using different acupoints and to prolong its effects.

7. Conclusion

This study suggests that acupressure, especially in the upper limbs and ears, may offer a short-term reduction in cardiac and non-cardiac pain, HR, and SBP in CAD patients when used alongside pharmacological treatments. It may be useful for preventing an increased heart workload and improving cardiac blood supply. Thus, with appropriate training and monitoring precautions, acupressure may be considered an adjunct treatment. Due to its ease of application, patients can be trained to use acupressure with proper instruction. However, due to the small number of included studies and low certainty of evidence, further strong clinical trials with longer follow-up periods are needed for a more certain conclusion.

Supplemental Material

Supplemental Material - Effect of Acupressure on Pain Severity and Vital Signs in Coronary Artery Disease: A Systematic Review and Meta-Analysis

Supplemental Material for Effect of Acupressure on Pain Severity and Vital Signs in Coronary Artery Disease: A Systematic Review and Meta-Analysis by Amirhossein Nasirmoghadas, Yekta Rahimi, Mohammad Bagher Yavari, Zahra Dinpajuh, Seyedeh Esmat Hosseini and Ladan Sedighi in Sage Open Nursing.

Footnotes

Acknowledgments

The authors would like to thank the Clinical Research Development Center officials of Shahid Modarres Educational Hospital.

ORCID iDs

Amirhossein Nasirmoghadas

Yekta Rahimi

Mohammad Bagher Yavari

Zahra Dinpajuh

Seyedeh Esmat Hosseini

Ladan Sedighi

Ethical Considerations

Ethical approval and informed consent are not required, as this is a systematic review and meta-analysis that only uses previously published data.

Author Contributions

Conceptualization & Investigation: Nasirmoghadas A, Sedighi L, Yavari MB, Dinpajuh Z. Writing – original draft: Nasirmoghadas A, Sedighi L, Yavari MB, Rahimi Y, Dinpajuh Z. Data analysis: Rahimi Y. Writing – review & editing: Nasirmoghadas A, Sedighi L, Rahimi Y, Hosseini SE.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets and protocol used and analyzed during the current study are available from the corresponding author on reasonable request.*

Trial Registration

CRD42024576400.

Supplemental Material

Supplemental material for this article is available online.

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