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Yoga-based cardiac rehab feasible after MI
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CHICAGO — Yoga-based cardiac rehabilitation for post-MI patients in low- and middle-income countries in India was safe, feasible and improved quality of life and return to pre-infarct daily activities.
“Cardiac rehabilitation is virtually nonexistent in low- and middle-income countries in India due to its high cost and the need for a multidisciplinary team. Even in high-income countries, uptake of cardiac rehabilitation is 25% to 35% and is particularly poor among the elderly and women who may prefer gentler and simpler approaches. There is a high unmet need for cardiac rehabilitation,” Dorairaj Prabhakaran, MD, DM, MSc, FRCP, FNASc, professor of chronic disease epidemiology and vice president at the Public Health Foundation of India and executive director of the Center for Chronic Disease Control, said at the American Heart Association Scientific Sessions.
Prabhakaran and colleagues looked at yoga as an alternative means to cardiac rehabilitation, as it addresses the same three main components: stress reduction, physical fitness and lifestyle changes.
Yoga vs. standard care
The study included 3,959 patients within 14 days of acute MI at 24 sites in India (mean age, 53 years; 14% women). More than 60% had undergone revascularization. At baseline, 54% of patients were physically inactive. There was a high standard of contemporary cardiac care in both arms, he said, with most patients using antiplatelet therapy or statins at baseline.
Patients enrolled underwent random assignment to the Yoga-CaRe cardiac rehabilitation program or enhanced standard care. The Yoga-CaRe program consisted of 13 sessions of meditation, breathing and yoga postures with trained yoga instructors. For comparison, the standard-care group received an informational leaflet and three educational sessions led by a nurse or other cardiac team member.
The trial failed to show significant benefit for the primary outcome of time to occurrence of first cardiac event, defined as a composite of death, nonfatal MI or stroke, and emergency cardiac admissions. While there are numerically fewer outcomes in the Yoga-CaRe group, the difference was not statistically significant, Prabhakaran said during a press conference. The composite primary outcome occurred in 6.7% of yoga participants compared with 7.3% of standard-care participants (HR = 0.91; 95% CI, 0.75-1.4), according to the intention-to-treat analysis. There were no differences in individual components of the primary outcome, either.
In a per-protocol analysis of patients who completed 10 or more Yoga-CaRe sessions, risk for the primary composite outcome was lower among those who participated in yoga (HR = 0.54; 95% CI, 0.38-0.76). This suggests a “potential dose-response relationship,” Prabhakaran said.
The trial had a second primary outcome of quality of life at 12 weeks, which showed a significant improvement in mean change in EQ-5D VAS score from baseline in the Yoga-Care group: 10.7 points compared with 9.2 points in the standard-care group (P = .002).
In other results, more participants who completed the Yoga-CaRe program returned to pre-infarct daily activities at 12 weeks (P < .001). Prabhakaran also reported improvements, albeit nonsignificant, in smoking cessation and adherence to prescribed medications at 12 weeks.
Prabhakaran acknowledged that the clinical outcomes were not different between the two groups due to inadequate power to detect the planned difference because of a lower-than-estimated event rate.
However, “Yoga-CaRe has the potential to be an alternative to the conventional cardiac rehabilitation programs and address the unmet needs of cardiac rehabilitation for patients in low-and middle-income countries,” he said.
Areas for future research
During a discussion of the trial, Vera Bittner, MD, MSPH, section head of general cardiology, prevention and imaging in the division of cardiovascular disease at University of Alabama at Birmingham, said that data are lacking on the effectiveness of yoga for secondary prevention in CHD.
“I think we can consider the Yoga-CaRe trial a true landmark trial in this area of research,” she said.
Bittner noted, however, several limitations of the study, including the low proportion of women (14%), relatively young population (mean age, 53 years) and no data on adverse events or injuries that may have occurred during the Yoga-CaRe program study period. Additionally, the enhanced standard care group lacked a physical activity intervention, “so we’re not really sure whether the effects we saw [in this study] are yoga-specific or whether a home walking program would have accomplished the potentially same results,” she said.
Questions remain, such as whether the results of this study can be translated to patients with MI in other settings, including outside of India and in older, sicker populations, Bittner said.
“Areas for future research might focus on the comparing yoga intervention with standard in-center cardiac rehabilitation and/or home-based rehabilitation and whether outcomes of standard cardiac rehabilitation could be improved further by integrating Yoga-CaRe into existing treatment protocols,” Bittner said. – by Katie Kalvaitis
Reference:
Prabhakaran D, et al. LBS.02 – Late Breaking Clinical Trials: Novel Approaches to CV Prevention. Presented at: American Heart Association Scientific Sessions; Nov. 10-12, 2018; Chicago.
Disclosures: Prabhakaran and Bittner report no relevant financial disclosures.
Perspective
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Martha Gulati, MD, MS, FACC, FAHA
This is a quite important study that was conducted in India, but it is likely something that we can translate to other places, like the United States, if patients aren’t interested in exercise or able to exercise as part of their cardiac rehabilitation. Exercise is daunting to many people and is a reason why a lot of patients don’t complete cardiac rehabilitation. For women, cardiac rehabilitation retention is much lower.
I was excited to see the results of this study because yoga can result in a lot of the same physiological effects that we try to achieve with cardiac rehabilitation. The study may not have showed an improvement in outcomes, which was the primary endpoint, but there was a quality of life improvement and many patients could return to their prior activities after the yoga program. I’d be curious we could ever compare, head to head, our traditional cardiac rehabilitation programs in the U.S. to a yoga-based program like this one conducted in India.
Maybe we need to more strongly consider and be open-minded about implementing alternative types of activity or cardiac rehabilitation for people that are a better fit for their lifestyle or that they might enjoy, like yoga. In the U.S., we have a multi-ethnic population and some people might feel more comfortable practicing yoga. An added bonus is that you don’t need equipment with the Yoga-CaRe intervention; you just need a room, or maybe go outside in some cities, yoga mats and an instructor who can ensure safety. Ultimately, the point is to get people to either be as active as they were before, or more active.
University of Arizona College of Medicine – Phoenix
Physician Executive Director for the Banner – University Medicine Heart Institute
Editor in Chief, ACC CardioSmart
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