Yoga may have potential for cardiac rehab in low- and middle-income settings

Yoga-based cardiac rehabilitation may have potential in post-myocardial infarction patients compared with enhanced standard care, according to a multicenter randomized controlled trial in India.

Presented during a Late-Breaking Clinical Trial session at Scientific Sessions 2018 in Chicago, the two primary outcomes of Yoga-based Cardiac Rehabilitation (Yoga-CaRe) were:

  • Time to occurrence of first cardiac event (composite of death, nonfatal MI and stroke) and emergency cardiac admissions
  • Quality of life at 12 weeks

Secondary outcomes included return to pre-infarct daily activities, smoking cessation and compliance to prescribed medications at 12 weeks, said Dorairaj Prabhakaran, MD, DM, executive director at the Center for Chronic Disease Control in New Delhi, India.

To be included in Yoga-CaRe, participants had to be within 14 days of acute myocardial infarction and willing and able to attend the complete cardiac rehabilitation program, Prabhakaran said. Participants self-reporting a current practice of yoga for more than three hours a week were excluded.

The yoga-based intervention was structured similar to cardiac rehabilitation programs and included lifestyle, meditation, breathing and yoga training sessions by trained yoga instructors for 13 weeks followed by self-practice at home.

The control group received ESC from a nurse or other member of the cardiac care team individually or in groups for five sessions.

The two treatment groups — 1,970 evaluable patients in Yoga-CaRe and 1,989 evaluable patients in ESC — were well-matched for baseline characteristics such as revascularization and cardiac medications. Median age was 53.4 years, which is typical for a cardiac event in the Indian population. Women represented only about 14 percent of the trial patients.

There were no statistically significant differences between the groups for the first co-primary outcome of death, non-fatal MI, non-fatal stroke or emergency cardiovascular hospitalizations.

Less than half the number of events occurred compared with the original assumption, so the study was underpowered. However, in patients who completed 10 or more Yoga-CaRe sessions, the incidence of cardiovascular events was significantly lower than those in the control group (HR 0.54; CI 0.38, 0.76; log rank test, P<0.0001).

For the second co-primary outcome, the mean change in EQ-5D VAS score, a measure of self-reported quality of life from baseline to three months was 9.2 in the ESC group versus 10.7 in the Yoga-CaRe group (P=0.002). It remained significant after adjusting for baseline covariates, risk profiles and treatments at discharge.

Yoga-based cardiac rehabilitation is safe, feasible, improves quality of life and encourages return to pre-infarct activities, Prabhakaran said. It has the potential to be an alternative to conventional cardiac rehabilitation programs and to address the unmet needs of patients in low- and middle-income countries for low-cost, culturally acceptable and effective cardiac rehabilitation, Prabhakaran said.

Three components of cardiac rehabilitation — stress reduction, exercise and lifestyle changes such as smoking cessation and healthier diet — could be addressed by yoga.

There are questions about whether Yoga-CaRe could apply to populations that are older, female or with more severe cardiac disease, according to discussant Vera Bittner, MD, MSPH, section head of General Cardiology, Prevention and Imaging in the Division of Cardiovascular Disease at the University of Alabama at Birmingham.

Patients in the ESC group had fewer contacts with study staff than the yoga group and didn’t have a physical activity intervention, so it is not known if they would have benefited from more contacts and physical activity. Only 53 percent of the yoga group completed at least 10 sessions, and Bittner wondered if adherence would have been worse outside of a clinical trial setting.

Other questions remain to be addressed, such as the potential for yoga to be integrated into existing treatment protocols, and whether it can be applied to other health care settings and populations.