Yoga and Atrial Fibrillation: Calm for the Heart and the Mind

Atrial fibrillation (AF) is recognized as a national epidemic in the United States with incidence increasing as the population ages. Newer treatment options, including ablation therapy and novel oral anticoagulants, have begun to change the landscape of the disease. However, AF continues to consume significant health care resources. 

An intriguing study by Lakkireddy and colleagues¹ called the Yoga My Heart Study and the first of its kind, suggests that regular practice of yoga may be an adjunctive non-pharmacologic alternative to help manage AF. The small cohort study was just published in the online version of Journal of the American College of Cardiology: 49 patients with paroxysmal AF and on a stable medical regimen were observed for a control period of 3 months. Following this, they all received 3 months of intensive yoga training that included twice-weekly 60-minute sessions as well as educational DVDs to practice with at home. Event rates, including number of symptomatic and asymptomatic AF episodes and symptomatic non-AF episodes were recorded by cardiac nonlooping event monitors.   

The average age of patients was 61 years and baseline average duration of AF was 5.3 years. At the end of the yoga intervention period, not only were there fewer non–AF-related symptoms reported (1.4 vs 2.9) and fewer symptomatic and asymptomatic AF episodes (2.1 vs 3.8), but there was also a decline in heart rate and systolic blood pressure values compared with those observed during the control period (P < .001). Twenty-two percent of patients who had documented AF during the control phase did not have any AF episodes during the yoga phase. Patients also reported significant improvements in multiple quality-of-life parameters, including physical function, general health, vitality, social functioning, and mental health (P < .02 for all). There were no apparent adverse effects reported with yoga training.

Although the mechanism underlying these findings remains unclear, the authors propose several possible physiologic explanations: an increase in parasympathetic tone; enhanced balance between the 2 autonomic nervous system components; reduced systemic inflammation and oxidative stress; and, decreased progression of arrhythmia by preventing or attenuating atrial remodeling. The non-physiologic explanations put forth include the presence of a more supportive environment in the yoga studio and formation of caring relationships and social interaction.      

This is not the first demonstration of the use of yoga in the management of cardiovascular disease, but it is the first study to examine the effects in AF. Previous research has  evaluated other non-invasive strategies, such as meditation, which in one study was associated with a significant reduction in the risk of all-cause mortality, MI, or stroke in African American patients with documented coronary heart disease.² Other outcomes, however, such as those from the recent  HARMONY study,³ in which participants with stage 1 hypertension followed an intensive, 10-week mindfulness-based stress-reduction program but did not achieve improved blood-pressure control,³  suggest that the Lakkireddy results may be a chance finding. 

Although larger randomized controlled studies are needed to establish this relationship, and additional cost-effectiveness analyses are forthcoming, this study opens the door for physicians and patients to explore another non-pharmacologic option for managing the ever-rising burden of AF. 

References:
1. Lakkireddy D, Atkins D, Pillarisetti J, et al. Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: the YOGA my heart study. J Am Coll Cardiol. 2013. doi:10.1016/j.jacc.2012.11.060. 
2. Schneider RH, Grim CE, Rainforth MV, et al. Stress reduction in the secondary prevention of cardiovascular disease: randomized, controlled trial of transcendental meditation and health education in blacks. Circ Cardiovasc Qual Outcomes. Published online ahead of print November 13, 2012. doi:10.1161/CIRCOUTCOMES.112.967406.  
3. Blom K, Baker B, How M, et al. Hypertension analysis of stress reduction using mindfulness meditation and yoga: results from a randomized controlled trial. Canadian Cardiovascular Congress (CCC) 2012. Wednesday, October 31, 2012; Toronto. Abstract 904.