Cardiovascular disease (CVD) is currently the leading cause of death worldwide, accounting for approximately 30% of all deaths.1 Whereas CVD used to be understood in terms of conditions (like atrial fibrillation or hypertension) or events (like myocardial infarction or angina), it is now seen as a “broad spectrum of illnesses comprising hypertension, atherosclerosis, heart disease, stroke, peripheral vascular disease, and aortic vascular disease and their associated complication.”2 Not only is CVD the leading cause of death worldwide, it is also one of the leading causes of morbidity and disability as people along the continuum are living in compromised bodies.
The medical understanding of CVD has expanded greatly in the past few years. Doctors and researchers now describe “CVD as a chain of events initiated by several risk factors such as dyslipidemia, hypertension, diabetes mellitus, smoking and obesity”3 which are known to promote oxidative stress and to cause endothelial dysfunction, initiating a cascade of events.4 Yoga has the potential to act at several levels of this chain of pathophysiological events.5
Treatment, therapy and rehabilitation for and of CVD are diverse, ranging from surgical, pharmaceutical and lifestyle changes. While surgical and pharmaceutical treatments continue to save and prolong lives, doctors and researchers have learned much more about how patient’s choices and care for themselves can be effective in prevention of and rehabilitation after CVD events, as well as increasing quality of life for CVD survivors. Yoga therapies are important parts of lifestyle choices and care.
It is generally acknowledged that the vast majority of CVD, at all stages along the continuum, is caused by lifestyle choices. The Lifestyle Heart Trial6, a study conducted by Dean Ornish and a team of doctors and researchers, was the first and remains one of the most robust studies regarding the ability of lifestyle changes to slow and even reverse heart disease. That randomized clinical trial, conducted from 1986 to 1992 measured changes in blood fat profiles, angina episodes, and changes in coronary artery percent diameter stenosis between groups of patients that followed intensive lifestyle changes – a 10% fat, whole foods, vegetarian diet; aerobic exercise; stress management training; smoking cessation; and group psychosocial support — and a control group. Yoga was part of the stress management component of the program.
The study showed that the patients in the lifestyle changes group had a 37.2% reduction in low-density lipoprotein (LDL) cholesterol levels and a 91% reduction in the frequency of anginal episodes. Average percent diameter stenosis regressed from 40.0% at baseline to 37.8%.7 The yoga in the Dean Ornish study was designed by Nischala Devi. The protocol she created for these patients included deep relaxation at several stages throughout each yoga session, not just at the end. The practice used for the trial can be found on Devi’s audio recording Relax, Move & Heal.8 The effectiveness of yoga as a rehabilitative therapy or treatment for CVD was not able to be determined by this study as it was one component among several in the therapy protocol. However, the study did show that heart disease is indeed reversible to some extent and that healing and health can be in one’s own hands.
Many have focused on the other parts of this study – the low fat diet, smoking cessation, aerobic exercise — for prevention, treatment and rehabilitation of heart disease. However, people who adhere to these components of a healthy lifestyle can find themselves with CVD, which indicates that there is more nuance to cardiovascular health. For example, Deane Delmas, a 72-year-old social worker from Texas, saw her lifestyle as extremely healthy when she had her cardiac event leading to an angioplasty. She ate a healthy diet and was a long distance runner competing in marathons. She seemed to already being doing everything to take care of her health and her heart. She said “After I got back on my feet again, I began to look at my schedule. It was all assertive, aggressive—lifting weights, brisk walking, and the like. Something was missing.”“9
It turns out how you are with and in your body matters especially to cardiovascular health and rehabilitation. The Western world has a colloquially identified a personality type called Type A, which refers to people who are “high strung, “ aggressive,” “achievement oriented,” “hard-driving.” These people are always “on,” don’t sleep enough, drink a lot of caffeine, are intense and have a sense of urgency about time. There are many ways to describe this “personality type.” In an Ayurvedic view these people are pittas or have excessive pitta dosha. They are fiery and intense and without balance. These personality traits and emotional dispositions have been strongly linked through multiple studies to heart attacks.10
The characteristics of Type A or excessive pitta dosha people are those of stress. Stress, very generally, is our response to environmental and psychosocial situations. Researchers have sought to be more specific about “normal” response to stress and stress responses that are “ abnormal” because they contribute to disease. The term allostatic load refers this kind of “abnormal” stress response.11 “When the brain perceives an experience as stressful, physiologic and behavioral responses are initiated leading to allostasis and adaptation. Over time, allostatic load can accumulate, and the overexposure to neural, endocrine, and immune stress mediators can have adverse effects on various organ systems, leading to disease.”12 Allopathic load is more than stress or even chronic stress; it “sets into motion adaptive processes that alter the structure and function of a variety of cells and tissues.”13
There is increasing evidence from clinical trials that the “mechanism of action by which yoga therapy helps patients with heart failure is likely due to autonomic nervous system modulation. It has been well established that in patients with heart failure there is sympathetic overdrive … yoga therapy facilitates the balancing of sympathetic and parasympathetic nervous systems”.14 Vascular surgeon Dilip Sarkar states that “yoga therapy for cardiovascular disease is primarily targeted to control the mind through deep internal awareness. This is achieved through relaxation of the physical body, effortless yogic breathing, and calming down the mind with prolonged savasana, pranayama, deep meditation, and mantra chanting.”15 Nischala Devi states, “we are trying to reverse the behavioral patterns of overachieving and pushing beyond limits.”16 Yoga seems to be an ideal intervention and rehabilitative therapy for addressing the stress, anger, and intense life orientation that are proven CVD risk factors.
The yoga protocols – or routines – used in treating CVD vary. The yoga is often, but not always, performed in a chair. The sequences focus on joint-freeing (neck, shoulders, wrists, ankles, hips), moving with the breath, gentle forward and backward bends, gentle inversion (viparita karani), deep relaxation (savasana), pranayama (slow breathing with the exhalation longer than the inhalation, possibly chaining OM on exhalation), and alternate nostril breathing (nadi shodhana). These yoga practices can intervene at virtually any stage along the CVD continuum and are particularly important for anyone already identified as being on the continuum or in cardiac rehabilitation after a cardiac event.
1 Khalsa, S.B.S., Cohen, L., McCall, T., & Telles, S., (Eds.). (2016, 2017). The Principles and Practice of Yoga in Health Care. United Kingdom. Handspring Publishing. P. 277
2 Khalsa, p. 277
3 Khalsa, p. 277, referencing Dzau, V.J., Antman, E.M., Black, H.R., Hayes, D.L., Manson, J.E., Plutzky, J., … Stevenson, W. (2006). The cardiovascular disease continuum validated: clinical evidence of improved patient outcomes: Part I: Pathophysiology and clinical trial evidence (risk factory through stable coronary artery disease). Circulation, 114(25), 2850-2870.
4 Khalsa, p. 277
5 Khalsa, p. 278
6 Ornish, Dean, et al. (1999). Intensive Lifestyle Changes for Reversal of Coronary Heart Disease. Journal of the American Medical Association. 280 (23). 2001-7
7 Ornish, p.2001
8 McCall, T., (2007). Yoga as Medicine: The Yogic Prescription for Health and Healing.New York, New York. Bantam Books.pp. 342-3
9 Barrett, J., Heart to Heart. (2007). Retrieved from https://www.yogajournal.com/lifestyle/heart-to-heart
10 McCall, p.377
11 University of California Medical Center (UCSFMC) Research Notebook on SES & Health: Allostatic Load Notebook. (2009).. Retrieved from https://macses.ucsf.edu/research/allostatic/allostatic.php
14 Khalsa, p. 285 referencing Kishi, T. (2012). Heart failure as an autonomic nervous system dysfunction. Journal of Cardiology, 59(2), 117-122.
15 Khalsa, p. 295
16 Khalsa, p. 295