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| Year : 2021 | Volume
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| Issue : 1 | Page : 26-35 |
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| A review on role of yoga in the management of patients with cardiac arrhythmias |
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Gautam Sharma1, Mooventhan A2, Gitismita Naik3, L Nivethitha4
1 Department of Cardiology, Center for Integrative Medicine and Research, All India Institute of Medical Sciences, New Delhi, India
2 Department of Research and Development, Government Yoga and Naturopathy Medical College, Chennai, Tamil Nadu, India
3 Department of Community and Family Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
4 Department of Naturopathy, Government Yoga and Naturopathy Medical College, Chennai, Tamil Nadu, India
Click here for correspondence address and email
| Date of Submission | 23-Jan-2020 |
| Date of Decision | 01-Jun-2020 |
| Date of Acceptance | 16-Jul-2020 |
| Date of Web Publication | 05-Feb-2021 |
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 Abstract | | |
Evidence suggests that yoga is safe and effective in improving various risk factors, quality of life (QoL), and psychological burden that is related to arrhythmia. However, this is the first-ever systematic review performed to report the role of yoga in arrhythmia. We have performed a literature search using Cochrane Library, Medline/PubMed, Web of Science Core Collection, and IndMED electronic databases up to 3, January 2018. Of 240 articles, 6 potentially eligible articles were identified and included in the review. Results showed that yoga could be considered an efficient adjuvant in reducing arrhythmia (paroxysmal atrial fibrillation, ventricular tachyarrhythmia, and palpitation) related health problems; blood pressure, heart rate, depression and anxiety scores; and in improving health-related QoL of arrhythmia patients. However, there is a lack of randomized controlled trials and a clear mechanism behind the effect of yoga; studies had relatively a small sample size and different yoga protocols.
Keywords: Arrhythmia, cardiovascular diseases, quality of life, yoga
How to cite this article:
Sharma G, Mooventhan, Naik G, Nivethitha L. A review on role of yoga in the management of patients with cardiac arrhythmias. Int J Yoga 2021;14:26-35 |
How to cite this URL:
Sharma G, Mooventhan, Naik G, Nivethitha L. A review on role of yoga in the management of patients with cardiac arrhythmias. Int J Yoga [serial online] 2021 [cited 2023 Mar 27];14:26-35. Available from: https://www.ijoy.org.in/text.asp?2021/14/1/26/308739 |
| Introduction | |  |
Cardiac arrhythmia (irregular heart rhythm) is the incapability of the ventricles and atria to contract in a regular rhythm due to a malfunction of electrical signals in the heart.[1] Based on the resting heart rate (HR), the arrhythmia is classified as either tachycardia ([HR >100 beats/minutes] or bradycardia [HR <60 beats/minutes]). Types of arrhythmia: (1) supraventricular arrhythmias (e.g. paroxysmal supraventricular tachycardia, and atrial fibrillation/flutter [AF]), (2) premature beats, (3) bradyarrhythmias (4) ventricular arrhythmias ([e.g., ventricular tachycardia [VT] and ventricular fibrillation/flutter [VF]).[2] Cardiac arrhythmias are widespread, particularly in patients with heart diseases[3] and are known to have an impact on health-related outcomes, and healthcare costs. The efficiency of existing treatments, including anti-arrhythmic drugs, is quite variable[4] and limiting its scope due to its adverse effects, including decreased quality of life (QoL). Thus, an intervention which is safe and effective in improving risk factors of arrhythmia would be effective in treating patients with arrhythmias and might have a major public health impact.
Yoga, a mind-body medicine originated in ancient Indian philosophy[5] approximately 5000 years ago[6] and is currently becoming popular as a safe and effective treatment modality in the Western countries.[5] It consists of specific posture (asana), breathing techniques (pranayama), and meditation.[4] Patients with arrhythmia also frequently complain of depression and anxiety,[4],[7] and impaired QoL.[6],[7] Whereas, the yoga practice is not only effective in reducing the psychological burden (depression and anxiety) and in improving the QoL that are associated with arrhythmia,[4] but is also safe and effective in managing various arrhythmia risk factors including autonomic dysfunction,[8] oxidative stress,[9] obesity,[10] hypertension,[11] coronary artery disease,[12] and heart failure.[13] Thus, the practice of yoga is believed to be an important modality in patients with arrhythmia, as corroborated by multiple studies in the past few years. Moreover, this review was performed with the aim and objective to systematically assess the role of yoga on arrhythmia episode, electrocardiogram (ECG) changes, hemodynamic changes, exercise capacity, psychological burden, and health-related QoL in patients with arrhythmia.
| Methods | | |
Eligibility criteria
Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to carry out this review.[14] Experimental studies including randomized controlled trials (RCTs), crossover or self as control trials, single group pre-post trials, case series that are dealing with yoga practice (irrespective of a particular type, duration, and frequency) and arrhythmia (any type) with or without comparing with standard medical care and published in English were eligible. Observational studies, case reports without yoga intervention, review articles, surveys, and health news were not eligible.
Database and search strategies
To find the relevant articles in English, we have carried out a literature search using Cochrane Library, Medline/PubMed, Web of Science Core Collection, and IndMED electronic databases up to January 3, 2018. We used the following search terms “Yoga AND Heart rate OR Atrial fibrillation OR Arrhythmia OR Arrhythmias in Medline/PubMed and keywords “Yoga and cardiac arrhythmia, or yoga and arrhythmia” in the rest of the electronic databases. Articles available from the literature search (n = 240) were screened, and potentially eligible articles were recognized and incorporated (n = 6) in this review. The summary of the search strategy is given in [Figure 1].
Data collection and analysis
Two authors independently screened the available literature using title and abstract to obtain the relevant articles. If the article seems to be eligible, then the full-text of that article was obtained and once again the eligibility was confirmed by those two authors independently. In the event of any discrepancy, third author was authorized to take a final decision after evaluating the article for eligibility. References of the eligible articles were cross-checked to find the other potentially eligible articles.
Data extraction
Data extraction was performed by two authors independently using a standard data extraction forms considering the study setup, study population, intervention performed, study duration, outcome variables, and results.
Risk of bias of the included randomized controlled trials
Two authors separately evaluated the included RCTs' risk of bias using Cochrane Collaboration modified tool for assessing the risk of bias for RCTs, Part-I and II. The following criteria were assessed: random sequence generation, selective reporting, allocation concealment, blinding of outcome assessment, blinding of participants and personnel, incomplete outcome data, and other sources of bias [Table 1]. | Table 1: Risk of bias assessment of included randomized controlled studies
Click here to view |
| Results | | |
In the literature review, a total of 240 articles published were available. Of 240 articles, 15 duplicates were eliminated and the remaining 225 articles were screened. Of 225 articles, six articles that fulfilled the eligibility criteria were included in the review. Of 6 articles (2 RCTs, 2 self as control trials, 1 single group pre-test and post-test experimental study and 1 case series) included in the study, two articles (1 RCT and 1 self as control trial) were published in the journal as conference presentations. The characteristics and the findings of the included articles are provided in [Table 2] and [Table 3]. | Table 3: Details of the subjects and the interventions of the included studies
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| Outcome measures and results | | |
Atrial fibrillation episodes
Two studies have evaluated the effect of yoga on the occurrence of AF episodes in paroxysmal atrial fibrillation (PAF) patients.[4],[15] AF (>30 s) was monitored using cardiac non-looping event monitors and a symptom diary during the study period. In order to differentiate between the asymptomatic and symptomatic AF episodes, patients were advised to record episodes whenever they had AF symptoms and if they did not have the symptoms, they were asked to record at least one recording per day. Asymptomatic AF, symptomatic non-AF episodes and symptomatic AF episodes were classified as the events coupled with AF on the monitor and no symptoms, the events coupled with no AF on the monitor and symptoms and events coupled with AF on the event monitor and symptoms respectively.[4] In these studies, the practice of yoga for 3 months has been shown to produce a significant decrease in the AF episodes (P < 0.001)[15] including asymptomatic-AF episodes (P < 0.001), symptomatic non-AF episodes (P < 0.001), and symptomatic-AF episodes (P < 0.001) in the yoga phase compared to the control phase. Moreover, (n = 11) i.e., 22% of patients those who had AF episodes in the control phase were not reported to have AF episodes in the yoga phase.[4]
Electrocardiogram findings
Two studies have evaluated ECG findings in patients with two different arrhythmias.[16],[17] One study reported the effect of 3 months practice of yoga on QT dispersion (QTd) (a myocardial electrical instability marker), JT dispersion (JTd) (sudden death in myocardial infarction predictor), HR-corrected QT (QTc) and JT intervals (JTc) [derived using Bazett's formula (QTc = QT/RR-1/2)] to determine ventricular repolarization dispersions in patients with ventricular tachyarrhythmia. According to the study, the practice of yoga, particularly pranayama (Bhastrika, Kapalbhati, Anilom-vilom, Bhramari, and Udgit pranayama) for 45-min/day, 3-days/week, for 3-months produced a significant reduction in the indices of ventricular repolarization dispersion [i. e. mean values of QTd (from 71 ms to 59 ms; P < 0.02), QTc-d (from 82 ms to 63 ms; P < 0.01), JTd (from 76 ms to 57 ms; P < 0.002), and JTc-d (from 84 ms to 61 ms; P < 0.001)] in patients with ventricular tachyarrhythmia. The mechanism for this effect was proposed to be due to an improvement in the autonomic functions, such as an increase in parasympathetic activity and a reduction in sympathetic activity as measured by QTd and JTd in this study.[16]
Another study has reported the effect of 2 months of practice of yoga on premature ventricular complexes in patients with palpitation. In this study, the practice of yoga, particularly yogic breathing (six cycles/min) and relaxation in Shavasana, for 6 days/week for 2 months has been shown to produce a reduction in palpitations episodes, ectopic frequency during tilt and no ectopics in a 5-min ECG in patients with palpitation with premature ventricular complexes.[17]
Hemodynamic parameters
Three studies have evaluated the effect of yoga on hemodynamic parameters such as HR, systolic blood pressures (SBP), and diastolic blood pressures (DBP).[4],[6],[7] In the first study, a significant decline in HR, SBP, and DBP was reported both in the control phase (66.9 beats/min to 64.7 beats/min, 135 mmHg to 133 mmHg, and 80.9 mmHg to 78.2 mmHg respectively; P < 0.05 for all) and in the yoga phase. However, a better reduction was reported after the yoga phase (64.7 beats/min to 61.5 beats/min, 133 mmHg to 127.7 mmHg and 78.2 mmHg to 74 mmHg, respectively; P < 0.001 for all).[4] In the second study, the practice of yoga has been shown to produce a reduction in HR (64 beats/min to 60 beats/min), SBP (137 mmHg to 132 mmHg) and DBP (83 mmHg to 77 mmHg), while the control group (CG) has been shown to produce the opposite effect, i.e., an increase in HR (65 beats/min to 69 beats/min), SBP (138 mmHg to 141 mmHg), and DBP (84 mmHg to 87 mmHg). Moreover, there was a significant decline in HR (P = 0.02), SBP (P = 0.03) and DBP (P = 0.007) in the yoga group (YG) compared to the CG.[6] In third study, 12 weeks of yoga practice has been shown to produce a significant reduction in HR (YG = 64 beats/min to 61 beats/min, CG = 65 beats/min to 70 beats/min; P = 0.024), SBP (YG = 137 mmHg to 132 mmHg, CG = 138 mmHg to 141 mmHg; P = 0.033) and DBP (YG = 84 mmHg to 77 mmHg, CG = 84 mmHg to 86 mmHg; P < 0.001) in the YG compared to the CG.[7]
Metabolic parameters and exercise capacity
Only one study has reported the metabolic changes, including maximal oxygen consumption (VO2 max), metabolic equivalents (METs), and anaerobic threshold during the pranayama practice. The assessment was made through breath to breath online gas analysis by a metabolic cart. The study showed an increase in VO2 max (from 15 mLO2/kg/min to 16 mLO2/kg/min) and exercise capacity (from 4 METs to 5 METs) after pranayama. However, the increase in VO2 max and METs was insignificant, and no change has been reported in anaerobic threshold from 12 mLO2/kg/min after pranayama in patients with ventricular tachyarrhythmias.[16]
Depression and anxiety
Two studies have evaluated the effect of yoga on depression and anxiety in patients with PAF. The level of depression and anxiety were assessed using the Zung self-assessment depression score and Zung self-assessment anxiety score, respectively. Both studies have reported a significant reduction in depression (P < 0.001) and anxiety (P < 0.001) scores after the yoga phase compared to after the control phase.[4],[15]
Health-related quality of life
Four studies have evaluated the effect of yoga on QoL.[4],[6],[7],[15] Of the 4 studies, 2 studies have used only the short form-36 (SF-36) health survey,[4],[15] while another two studies have used a combination of the SF-36 health survey and the Euro-Qol-5 dimension visual analog scale (EQ-5D VAS) to evaluate the QoL.[6],[7]
Of two studies that used SF-36 alone, one study has showed a significant enhancement in general health (P < 0.05) after the control phase,[4] while another study did not provide any information regarding the control phase.[15] However, both the studies have reported a significant improvement in physical functioning (P = 0.017), general health (P < 0.001), vitality (P < 0.001), social functioning (P = 0.019), and mental health (P < 0.001) after the yoga phase compared to after the control phase.[4],[15]
Of two studies that used SF-36 with EQ-5D VAS, only one study has reported a significant improvement in both physical (P = 0.01) and mental (P = 0.02) health-related QoL in SF-36 and a significant improvement in EQ-5D VAS (P < 0.05) QoL in the YG compared to the CG.[6] Whereas, another study has been reported a significant improvement only in the mental health domain of SF-36 (P = 0.016) in the YG compared to the CG with a significant improvement in EQ-5D VAS-scale (P = 0.001) QoL in the YG ([only in the within-group analysis [P = 0.001] and not between-group analysis [P > 0.05]) and no significant change in the physiological health domain of SF-36 either in within or between the YG and the CG.[7]
Compliance and safety
Of six studies, only one study has reported the compliance to the yoga class (i.e., good compliance with the average of three classes that was varied from two to seven classes/week) and also revealed that the number of classes was not associated with the degree of improvement.[4] Of 6 studies, number of subjects completed the study was not available; thus, 5 studies attrition rate was calculated using a formula ([number of subjects dropped out from the study/number of subjects enrolled in the study] × 100) and the retention rate was calculated using a formula (number of subjects completed the study/number of subjects enrolled in the study × 100). Results showed that the included studies attrition rate was varied from 0% to 13.75% (i.e.[n = 2] had 0%,[16],[17] (n = 2) had 5.77%,[4],[15] and (n = 1) had 13.75%[7]) and retention rate was varied from 86.25% to 100% (i.e., [n = 1] had 86.25%,[7] [n = 2] had 94.23, and [n = 2] had 100%). This suggests that compliance with the study is good among patients with arrhythmias. Of six studies, only one study[4] has stated that there were no major adverse effects due to yoga therapy. However, none of the studies have reported any adverse effects during the practice of yoga and the entire study duration due to yoga practices. This suggests that the practice of yoga could be considered as a safe modality among patients with arrhythmias.[4]
| Discussion | | |
Yoga practices provided to the participants: Of 6 studies, only 3 studies[4],[16],[17] have reported the list of individual yoga practices provided to their study participants, while the rest of the studies[6],[7],[15] reported the yoga practices in general such as breathing exercises, asanas, meditation, and relaxation. The details of the individual yoga practices provided in Lakkireddy et al., 2013 study are 60 min of structured Iyengar yoga training (at least twice/week for 3 months) consists of 10 min of pranayamas such as ujjayi (sounding breath), dirghapranayama (Complete or three-part or yogic breathing), and nadishodhana pranayama (alternate nostril breathing), 10 min of warm-up exercises, 30 min of asanas such as sukhasana (easy posture), bitilasana (cow posture), adhomukhavirasana (modified child posture), dandasana (stiff posture), janusirsana (modified head on knee posture), paschimottanasana (intense back stretch posture modified), tadasana (mountain posture), uttanasana (intense forward stretch posture, setubandha sarvangasana (full-bridge posture), sputa padangusthasana (reclining big toe posture), pavanamuktasana (wind relieving posture), and shavasana (corpse posture), and 10 min of relaxation and meditation in savasana.[4] The details of the individual yoga practices provided in Dabhade et al., 2012 study are 45 min (3 sessions/week for 3 months) of pranayama practices including 10 min of bhastrika, 10 min of Kapalbhati, 15 min of Anilom-vilom, 5 min of Bhramari, and 5 min of Udgit pranayama (OM chanting).[16] Moreover, the details of the individual yoga practices provided in Ravindra et al., 2006 study are yogic breathing (at the rate of 6 breath/min) and shavasana for 6 days/week for 2 months.[17]
In summary, the duration of the yoga practices was 45 min[15],[16] to 60 min[4],[6],[7] a day, one day[6],[7] to 6 days[17] a week for a period of 2 months[17] to 3 months.[4],[6],[7],[15],[16] Pranayama or deep breathing practices were most commonly provided in all the studies. Next to pranayama, relaxation and meditation were provided in all the studies except one study.[16] Next to relaxation and meditation, asanas (simple practices modified as per the need of the patients)[4],[7],[15] or light movements[6] were provided to the study participants.
Summary of evidence
The practice of yoga was safe[4] and effective in reducing the number of AF episodes[4],[15] (i.e., asymptomatic-AF, symptomatic non-AF, and symptomatic AF episodes),[4] SBP, DBP, HR,[4],[6],[7] depression and anxiety scores and in improving some aspects of health-related QoL in patients with PAF.[4],[15] The practice of yoga has been shown to produce a significant reduction in mean values of QTd, JTd, QTc-d, and JTc-d suggestive of a decline in the ventricular repolarization dispersion indices with an insignificant increase in exercise capacity and VO2 max in patients with ventricular tachyarrhythmia.[16] Similarly, yoga has been shown to produce a reduction in palpitations episodes, ectopic frequency during tilt, and ectopics in palpitation patients with premature ventricular complexes.[17]
In a review article, lifestyle modifications, including yoga have been reported to be beneficial in reducing the incidence of AF in inducing more AF remission and also in producing successful ablation outcomes.[18] In another review, yoga has been reported to be associated with reductions in AF burden and symptoms. This suggests that the findings of this review are consistent with the findings of the other review articles.[19]
Limitations
Of six articles included in the review, two articles[6],[15] (1 RCT[6] and one self as control trial[15]) were published in the journal as conference presentations. These two articles[6],[15] looks similar in terms of subjects, sample size, and study design to two other articles[4],[7] that were included in this review. However, they were different in terms of either duration of the intervention[4],[15] or the outcome results.[6],[7] Of the six articles included, only two studies[6],[7] (including one conference presentation)[6] are RCTs. In contrast, another four studies[4],[15],[16],17] were non-randomized experimental studies including 2 self as control trials[4],[15] (including 1 conference presentation),[15] 1 single group pre-test and post-test trial[16] and 1 case series.[17] This suggests that there is a lack of RCTs in exploring the role of yoga in patients with arrhythmias. Even though there are two RCTs,[6],[7] none of the studies reported the effect of yoga on AF episodes or ECG changes in patients with PAF. And, they have reported only two domains of SF-36 health-related QoL, i.e., physical and mental leaving the rest of the domains. Moreover, the reason for not including those health domains was not discussed in the articles.[6],[7]
Of 6 studies, only three studies[4],[16],[17] have reported the list of individual yoga practices provided to their study participants, while the rest of the studies[6],[7],[15] reported the yoga practices in general. It is limiting the application of the yoga practices provided in those studies in a clinical set-up. In one study, though the total duration of the intervention was mentioned, the session durations followed every day were not been mentioned, which limits its application in clinical practice.[17] Of three studies that reported the role of yoga on BP and HR[4],[6],[7] only one study has reported how the BP was measured (i.e., using automated BP meter [OMRON], after 5 min of rest in sitting posture). However, how the HR was assessed (either manually or using the same automated BP meter) was not clearly mentioned.[7] Of six studies, yoga intervention was given for 3 months in five studies,[4],[6],[7],[15],[16] while it was given for only 2 months in one study[17] and none of the studies have followed the subjects for a longer duration. Thus, all of these studies have reported only the short-term effect of yoga without exploring the long-term effects associated with it. The studies had a relatively small sample size and that the yoga protocol and frequency were not standardized enough to make a significant effect.
Even though there are various types of arrhythmias,[2] studies have evaluated the role of yoga only on few types of arrhythmias including PAF (n = 4),[4],[6],[7],[15] ventricular tachyarrhythmia (n = 1)[16] and premature ventricular complexes (n = 1) and not on the other types of arrhythmias.[17] This is limiting the data on the application of yoga in all types of arrhythmias. Although autonomic dysfunction,[20] inflammation,[21] and oxidative stress[2] play important roles in the development of arrhythmias, and the practice of yoga has been shown to be effective in improving autonomic functions[13] and in reducing inflammation[22] and oxidative stress,[9] none of the studies reported the effect of yoga on autonomic functions, inflammatory markers or oxidative stress markers in patients with arrhythmias. The clinical significance of the studies reviewed was not performed due to the heterogeneity of the studies. This suggests that further studies and exploration needs to be undertaken to fully understand the mechanism that leads to the reduction of symptoms in patients with arrhythmia in the practice of yoga.
Future directions
Long-term well-planned RCTs in patients with various types of arrhythmias are required to enhance the understanding of yoga's effect with a precise mechanism.
| Conclusion | | |
Based on the available literature the review suggests 45–60 min of the following yoga practices at least 3 days/week to reduce arrhythmia burden: (1) Joint (warm-up) exercise (10 min), (2) Asanas such as sukhasana, bitilasana, adhomukhavirasana, dandasana, janusirsana, tadasana, uttanasana, pavanamuktasana and shavasana (15–25 min), (3) pranayamas such as slow and deep breathing or dirghapranayama, nadishodhana, bhramari, ujjayi and udgit pranayamas (OM chanting) (10–15 min) and (4) Relaxation in shavasana and meditation (10 min). However, it is always better to learn the techniques and practice under the supervision of institutionally qualified yoga experts in a clinical set-up to avoid untoward effects.
Results of this review suggest that yoga could be considered an efficient adjuvant in reducing arrhythmia burden in patients with PAF, ventricular tachyarrhythmia and palpitation; in reducing BP, HR, anxiety and depression scores; and in improving some aspects of health-related QoL especially mental health. However, there is no improvement in exercise tolerance in patients with tachyarrhythmia and a lack of a clear mechanism behind the effect of yoga. Thus, more studies are necessary to warrant the role of yoga in various types of arrhythmias with possible mechanisms.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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Correspondence Address:
Mooventhan A
Department of Research and Development, Government Yoga and Naturopathy Medical College, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijoy.IJOY_7_20
[Figure 1]
[Table 1], [Table 2], [Table 3] |
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