1. Manoj Sharma, Taj Haider, & Paul Branscum
A systematic review of yoga interventions as alternative and complementary treatment in cardiovascular disease.
Manoj Sharma, Taj Haider, & Paul Branscum
Monday, November 2, 2015; 12:30 pm – 1:30 pm
Session 3207; Poster display
143rd American Public Health Association Annual Meeting

2. Cardiovascular diseases
It is estimated that by the year 2030 the number of deaths as a result of cardiovascular disease will reach 23.6 million.
Risk factors:
Hypertension
Hyperlipidemia
Hyperglycemia
Abdominal and visceral obesity
Depression
Anxiety
Stress

3. Shortcomings of current therapies
Pharmacological therapy for cholesterol, blood pressure, etc.) is cost prohibitive
Pharmacological therapy is inappropriate due to deleterious side effects
Implantable cardioverter defibrillator (ICD) can also increase anxiety and depressive symptoms – increasing the heart rate of these patients that could lead to heart attack and death. It is estimated that, in some instances, as many as 46% of patients with ICDs experience anxiety and nearly the same percentage experience depression

4. Role of Exercise & Yoga
Exercise has shown favorable changes in cardiovascular disease factors:
Improving HDL
Decreasing LDL
Reducing blood pressure
Vigorous-intensity exercise is inappropriate for patients suffering from cardiovascular disease
Yoga, a mind-body intervention, consists of low-intensity physical postures that stimulate the parasympathetic nervous system inducing the relaxation response imperative for patients with or at-risk for cardiovascular disease

5. Yoga for CVD
Yoga originated in India as part of the spiritual practice for hundreds of years
Path to reduce stress, anxiety, and depression in both healthy and mentally ill adults
Combines physical postures with breathing techniques and meditation
It is a lifestyle intervention that can result in improved cardiorespiratory fitness
Yoga is studied for its efforts to reduce the psychological and physical risk factors associated with cardiovascular disease.

6. Research Questions
Is yoga an efficacious form of therapy to reduce risk factors associated with cardiovascular disease?
Are the articles reviewed comprised of valid research studies?
Is there sufficient data to draw conclusions about the efficacy of yoga for cardiovascular disease?

7. Inclusion criteria for studies
The inclusion criteria for this review included studies that were:
(a) Published in the English language between 2005 and 2015
(b) Indexed in MEDLINE/PubMed, CINAHL, or Alt HealthWatch
(c) Employed a quantitative design
(d) Applied a yoga intervention

8. Phase II: Distillation Phase III: Manuscript Review
Phase I: Boolean Logic
CINAHL, Medline, Alt Health Watch
Terms: Yoga AND Cardiovascular disease 1/ /2015
Figure: Data Extraction of studies chosen for this systematic review
Total Articles Returned: 315
Medline: 257
Atl Health Watch: 37
CINAHL: 21
Duplicate Articles
n=33
Review/Discussion/Secondary Data Articles n=169
Study did not incorporate yoga or measure cardiovascular factors or was on hypertension n= 99
Qualitative design
n= 1
Phase II: Distillation
Total Articles Excluded: 302
Total Articles Included: 13
Phase III: Manuscript Review
Total Articles Excluded
(n=1)
No evaluation results only protocol (n=1)
Articles satisfying inclusion criteria, distillation, and manuscript review
(n=12)

9. Results: Interventions 1 & 2
Year
Authors/ Country
Design, Sample &
Setting
Age
Intervention Modality
Intervention Dosage
Outcome measures
Salient Findings
2005
Bijlani, Vempati, Yadav, Ray, Gupta, Sharma, Mehta, and Mahapatra11 – India
Pretest-Posttest design (n=98) of subjects with hypertension, coronary
artery disease, diabetes mellitus, and/or a variety of other illnesses
20-74 years
Asanas (postures), pranayama (breathing exercises), relaxation
techniques
Integrate program of 3-4 hours daily of practice and theory for eight days
Fasting glucose, cholesterol; Low-density lipoproteins (LDL) and High-density lipoproteins (HDL), and triglycerides were measured
Fasting plasma glucose, total cholesterol, LDL, VLDL, triglycerides, and total cholesterol/HDL ratio were all significantly lower (pre vs. post). HDL cholesterol was significantly higher post-test (p<0.001).
2006
Marshall, Vernalis, Remaley, Walizer, Scally, and Taylor6 – USA
Pretest-Posttest design (n=96) of adults known to have coronary risk factors or coronary artery disease
Adults > 18 years
Yoga and supervised exercise
From weeks 2-12 (of the three month intervention) subjects had twice weekly yoga and exercise sessions (4 hours)
Blood pressure, heart rate, weight, BMI, body composition, LDL, and HDL measurements
Fitness level improved (pre to post) by 22% (p<0.0005). Significant decreases in LDL (13%). Significant increases in triglyceride HDL (28%). Largest HDL decrease was in the subgroup that exercised the least, but decreased their fat intake the most

10. Results: Interventions 3 & 4
Year
Authors/ Country
Design, Sample &
Setting
Age
Intervention Modality
Intervention Dosage
Outcome measures
Salient Findings
2009
Howie-Esquivel, Lee, Collier, Mehling, and Fleischmann3 – USA
Pretest-Posttest design (n=12) of patients with heart failure
30-74 years
A modified yoga program (with a focus on pranayama – breathing) for patients with past injuries
Eight weeks of three times weekly one hour yoga classes and a CD for at-home practice
Physical function measures, endurance tests, Quality of Life assessment, Beck Depression Inventory, and the Kentucky Inventory of Mindfulness Skills
Quality of Life symptom stability sub-scale significantly improved (p=0.02).
2010
Pullen, Thompson, Benardot, Brandon, Mehta, Rifai, Vadnais, Parrott, and Khan9 – USA
Randomized control design (n=40) of patients with ischemic or non-ischemic etiology of heart failure randomized to a yoga or control group
31-76 years
Low-intensity yoga
One hour yoga sessions twice weekly for a total of 16 sessions
Living with Heart Failure Questionnaire, EKG tests, plasma sampling, and a Quality of Life assessment
Significant increases in treadmill time (p=0.002) and maximum oxygen uptake (p=0.003) for yoga group compared to pretest. Plasma serum levels of Interleukin 6 (IL-6), and C Reactive Protein (CRP) decreased significantly in the yoga group (pre vs. post-test).

11. Results: Interventions 5 & 6
Year
Authors/ Country
Design, Sample &
Setting
Age
Intervention Modality
Intervention Dosage
Outcome measures
Salient Findings
2011
Pal, Srivastava, Tiwari, Verma, Narain, Agrawal, Natu, and Kumar12 – India
Randomized control design (n=154) of patients with coronary artery disease randomized to yoga or control groups
40-75 years
Medication + Yoga
35-40 minutes/day five days of week for six months of yoga practice
Body fat, Body mass index (BMI), fat mass, and cholesterol levels were measured
Significant decreases in fat percentage, BMI, fat free mass, systolic and diastolic blood pressure, heart rate, total cholesterol, HDL and, LDL among yoga group (pre to post).
2013
Pal, Srivastava, Narain, Agrawal, and Rani13 – India
Randomized control design (n=258) of patients with coronary artery disease randomized to yoga and non-yoga groups.
35-82 years
18 months of five days a week minute yoga sessions.
Autonomic functions, heart rate, blood pressure, and isometric strength were measured
BMI, waist: hip ratio, heart rate, Systolic and Diastolic BP decreased significantly in yoga vs. control group (p<0.01).

12. Results: Interventions 7 & 8
Year
Authors/ Country
Design, Sample &
Setting
Age
Intervention Modality
Intervention Dosage
Outcome measures
Salient Findings
2013
Sarvottam, Magan, Yadav, Mehta, and Mahapatra14 – India
Pretest-Posttest design (n=30) overweight or obese male subjects (BMI ≥ 23 to < 35 kg/m2)
18-55 years
Unspecified yoga
Two hours daily for ten days of yoga practice and theory and a nutrition awareness program
Body weight, BMI, height, blood pressure, and lipid profiles
Significant weight loss for participants (p<0.001) resulting in significant reduction in BMI (p<0.001). Reduction in pulse rate (p=0.02) and systolic BP (p=0.042). Clinically meaningful improvement in serum lipid profile (n.s.)
Toise, Sears, Schoenfeld, Blitzer, Marieb, Drury, Slade, and Donohue5 – USA
Randomized control design (n=46) of implantable cardioverter defibrillator (ICD) recipients randomized to standard medical (control) or yoga groups
Adults >18 years
Unspecified Yoga program
Eight weekly sessions of 80 minute yoga and a 30-minute at home yoga CD to be performed 3x a week
Florida Shock Anxiety Scale, Center for Epidemiologic Studies Depression, Positive Health Expectation Scale, State-Trait Personality Inventory, etc.
Yoga group had significantly fewer device-treated ventricular (DTV) events than the control group. Yoga group had a 32% lower risk relative to control of experience DTV events. Anxiety also decreased significantly in the yoga group (pre to post intervention) while it increased significantly for the control group.

13. Results: Interventions 9 & 10
Year
Authors/ Country
Design, Sample &
Setting
Age
Intervention Modality
Intervention Dosage
Outcome measures
Salient Findings
2014
Krishna, Pal, Pal, Balachander, Jayasettiaseelon, Sreekanth, Sridhar, and Gaur4 – India
Randomized control design (n=130) patients with heart failure randomized to a yoga or standard medical therapy groups
Yoga: 49.34±5.70
Control: 50.14±4.54
Modified yoga focusing on pranayama breathing techniques
12-weeks of three times weekly 60 minute yoga sessions
Heart rate, blood pressure, heart rate variability, and RPP (measurable index of myocardial oxygen consumption and load on the heart)
Significant decrease in HR, RPP, systolic BP, and diastolic BP, and HRV (low frequency) for yoga group (pre vs. post).
Yadav, Magan, Yadav, Sarvottan, and Netam15 – India
Pretest-Posttest design (n=238) of Indian adults
38.81±11.40
Integral Health Clinic yoga program with asanas and pranayamas
Two-weeks of 10 total two hour yoga sessions followed by an interactive lecture on stress management and nutrition
Lipid profile, BMI, blood pressure, and blood glucose
Significant increase in HDL, significant reduction in blood pressure and BMI (pre vs. post)

14. Results: Interventions 11 & 12
Year
Authors/ Country
Design, Sample &
Setting
Age
Intervention Modality
Intervention Dosage
Outcome measures
Salient Findings
2015
Siu, Benzie, and Woo7 – China
Randomized control design (n=182) of adults diagnosed with Metabolic Syndrome randomized to either a yoga or health status assessment questionnaire (control) group
56±9.1
Hatha yoga
Year-long thrice weekly 60-minute Hatha yoga sessions
Systolic and diastolic blood pressure, fast glucose, waist circumference triglycerides, HDL-c, and depression
Significant decreases in waist circumference and blood pressure (yoga vs. control group posttest) (p<0.005)
Yadav, Singh, Singh, and Pai16 – India
Randomized control design (n=80) of patients with coronary artery disease randomized to a yoga or conventional medicine (control) group
45-65
Yoga regimen of yogasanas and pranayamas
Three-month six days a week of 60-minute yoga practice followed by lectures/group discussions regarding life style change, weight management, stress, anxiety, and diet followed by ten weeks of at-home practice.
Pulmonary function measurements – slow vital capacity, forced expiratory volume, and maximum voluntary ventilation
Significant improvement in almost all pulmonary function measurements (yoga group pre vs. post). No significant improvements for control (pre vs. post)

15. Discussion…1
Of the 12 interventions, seven took place in India, four took place in the United States, and one took place in China
Of the 12 studies, all measured significant improvements in some component of cardiovascular disease, including both physical and mental factors: Body Mass Index (BMI), blood pressure, cholesterol, anxiety, depression, quality of life, weight, and pulmonary function

16. Discussion…2
In this review, five studies utilized pretest-posttest design while the remaining seven implemented randomized control trials (RCTs).
The duration of studies ranged from eight days to one year.
Similarly, the dosage of the intervention ranged dramatically: Higher dosage may play a role in improving cardiovascular risk factors

17. Limitations of interventions
No study offered any type of quality assessment tool of the instructors:
Terms like “yoga experts,” & “supervised sessions” were used in some studies
Different schools of yoga so difficult to compare
Small sample sizes
Not all RCTs

18. Recommendations
Only seven interventions utilized randomized control design which should be used in all studies
Only three interventions addressed the psychosocial components of cardiovascular disease which should be done in all studies
Standardization of techniques, duration, & dosage is needed
Need to have an in-home component
Need to have behavioral theories guide the intervention