REVIEW

Yoga and meditation in cardiovascular disease

S. C. Manchanda • Kushal Madan

Received: 11 September 2013 / Accepted: 3 January 2014

� Springer-Verlag Berlin Heidelberg 2014

Abstract Yoga is a holistic mind–body intervention

aimed at physical, mental, emotional and spiritual well

being. Several studies have shown that yoga and/or medi-

tation can control risk factors for cardiovascular disease

like hypertension, type II diabetes and insulin resistance,

obesity, lipid profile, psychosocial stress and smoking.

Some randomized studies suggest that yoga/meditation

could retard or even regress early and advanced coronary

atherosclerosis. A recent study suggests that transcendental

meditation may be extremely useful in secondary preven-

tion of coronary heart disease and may reduce cardiovas-

cular events by 48 % over a 5-year period. Another small

study suggests that yoga may be helpful in prevention of

atrial fibrillation. However, most studies have several

limitations like lack of adequate controls, small sample

size, inconsistencies in baseline and different methodolo-

gies, etc. and therefore large trials with improved meth-

odologies are required to confirm these findings. However,

in view of the existing knowledge and yoga being a cost-

effective technique without side effects, it appears appro-

priate to incorporate yoga/meditation for primary and

secondary prevention of cardiovascular disease.

Keywords Hatha yoga � Transcendental meditation �Hypertension � Metabolic syndrome � Dyslipidemia �Coronary heart disease

Yoga and meditation in cardiovascular disease

The word ‘Yoga’ comes from a Sanskrit word ‘YUG’

which means to yoke or join together. It connotes joining

the lower human nature to the higher [1]. Originating in

India about 4,000 years ago, the practice of yoga has

become increasingly common in the western countries [2–

6]. Ancient texts have described several types of yogic

practices. These include

Bhakti Yoga emphasizes devotion and spirituality

Gnana Yoga emphasizes wisdom

Karma Yoga emphasizes self-less services, offerings

Raj Yoga emphasizes mastery of mind by focused

concentration

Dhyana Yoga emphasizes meditation

Mantra Yoga emphasizes repetition of sacred recitation

like trancendental meditation and

Hatha Yoga emphasizes psychosocial energies of body

[1, 7]

Hatha yoga is most commonly practiced in the western

countries and which itself includes many different styles

(e.g. Iyenger, Ashtang, Anasara, Kundalini, Integral and

Bikram yoga which is practiced in very high temperatures

and may not be suitable for cardiac patients). Core com-

ponents of Hatha yoga include stretching exercises and

physical postures (Asanas), breath control (Pranayama) and

concentration and thinking techniques (Meditation)

designed to promote physical, mental, emotional and

spiritual well being. Yoga is believed to help detoxify the

body, mitigate chronic fatigue, enhance endurance and

improve organ and immune functions [7]. Beneficial

effects of yoga/meditation have also been reported in

allergies, asthma, anxiety, depression, acid peptic disease,

irritable bowel syndrome, migraine, diabetes mellitus,

cardiovascular disease (CVD), etc. [8]. Yoga appears to be

S. C. Manchanda (&) � K. Madan

Dharma Vira Heart Center, Sir Ganga Ram Hospital,

New Delhi 110060, India

e-mail: doctormanchanda@yahoo.com

123

Clin Res Cardiol

DOI 10.1007/s00392-014-0663-9

especially beneficial for CVD. This article will review the

evidence-based usefulness of yoga in the primary and

secondary prevention of CVD.

The literature search was focused on recent research that

primarily assessed the effects of yoga/meditation on risk

factors for coronary heart disease and secondary prevention

studies. Articles were identified using MEDLINE, Pub-

Med. As a number of studies investigating the effect of

yoga have been conducted in Indian subcontinent and these

databases offer only incomplete capture of articles pub-

lished in Indian Medical Journals, IndMED a bibliographic

database of over 75 Indian biomedical journals was also

searched.

Yoga for control of risk factors for CVD

Modern lifestyle stresses have been shown to be major

contributory factors to many diseases including CVD.

A US-based study has shown that mindfulness-based stress

reduction (MBSR) such as yoga reduced the average

number of visits to primary care physicians in inner city

areas suggesting that yoga may contribute in general health

and particularly in cardiac health in populations that are

subject to significant mental stress [9]. Many other studies

suggest that yoga/meditation practices can control heart

disease risk factors like hypertension, diabetes mellitus,

metabolic syndrome, obesity, psychosocial stress, dyslipi-

demia, oxidative stress, etc. and which are discussed

below.

Yoga and hypertension

Several controlled and uncontrolled studies have shown the

short- and long-term usefulness of yoga in the treatment of

hypertension [10–30]. In earlier studies Shavasana (Corpse

posture) and transcendental medication (TM) were repor-

ted to lower both systolic and diastolic blood pressure

significantly [10, 11]. Many randomized trials and meta-

analyses have also demonstrated a modest but consistent

decrease in blood pressure with yoga/meditation [10–30].

In a randomized trial, yoga was found to be equally

effective as anti hypertensive therapy over 11 week period

[19]. Another randomized controlled trial demonstrated

that yoga and biofeedback were capable of producing long-

term beneficial effect in the treatment of hypertension [29].

A meta-analysis involving nine well-controlled randomized

trials showed that TM compared to control was associated

with a decrease of systolic blood pressure of 4.7 mmHg (CI

1.9–7.4) and diastolic blood pressure of 3.2 mmHg (CI

1.3–5.6) [28]. Although the reduction in blood pressure by

yoga and meditation is modest, this could significantly

decrease the risk of CVD, because it has been estimated

that reducing systolic blood pressure by 3 mmHg in gen-

eral population has the potential to reduce stroke mortality

by 8 % and coronary heart disease (CHD) by 5 % [31, 32].

The possible mechanism of reduction of blood pressure is

considered to be reduced sympathetic activity and resto-

ration of baroreceptor sensitivity by yoga [17].

Yoga and metabolic syndrome

Metabolic syndrome is a strong risk factor of coronary

heart disease and type 2 diabetes mellitus. Regular practice

of yoga/TM have been shown to improve several compo-

nents of metabolic syndrome like insulin resistance, body

mass index, waist circumference, dyslipidemia, blood

pressure and HbA1c [33–37]. Yoga has also been reported

to regress early atherosclerosis in metabolic syndrome as

assessed by carotid intimal-medial thickness [37].

Yoga and type 2 diabetes mellitus

Yoga has been shown to be a simple and cost-effective

therapeutic modality as an adjuvant for type 2 diabetes

mellitus (DM) patients [38–42]. In a group of diabetics

who practiced yoga regularly, there was a reduction in

hyperglycemia and decrease in oral hypoglycemic drugs to

maintain adequate blood sugar control [38].

Yoga and body weight

Body weight and composition have been shown to be

consistently improved by yogic intervention. Five RCT’s

[43–46] have demonstrated an improvement in body

weight and/or composition relative to controls. These

studies have been performed in healthy individuals as well

as those with hypertension and other CVD risk factors, type

2 diabetes mellitus and CHD. Yoga was associated with

1.5–13.5 % decrease in body weight.

Yoga and lipid profile

Practice of yoga and yoga-based programs may improve

lipid profiles in healthy adults and in patients with diabetes,

hypertension and CHD. Four uncontrolled and four con-

trolled studies that range from 6 weeks to 12 months in

duration showed significant improvement in lipid profile

(reduction in LDL-c and triglycerides (Tg) and increase in

HDL-c over control values [44, 47–49]. Several RCTs

investigating the effect of yoga in combination with diet,

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123

education, stress management and other therapies have

likewise demonstrated a significant improvement in lipid

profiles relative to controls receiving usual care. The

magnitude of reduction of total cholesterol has varied

between 5.8 and 25.2 %, Tg between 22.0 and 28.5 % and

LDL-c by 12.8–26 % in these studies. A recent randomized

parallel study has also demonstrated a significant decrease

in total cholesterol, Tg and LDL-c with an improvement of

HDL-c in diabetic patients with dyslipidemia [50].

Yoga and psychosocial stress

Psychosocial stress is a significant major predictor of

hypertension, stroke, myocardial infarction, insulin resis-

tance and cardiovascular mortality. There is a strong

experimental evidence to suggest that yoga can lead to

improvement in both cardiovascular response to stress and

cardiovascular recovery from stress [51–53]. Several

studies also suggest that stress can be reduced significantly

with regular practice of yoga and meditation [5, 7, 8].

Yoga and procoagulant changes and oxidative stress

Procoagulant changes and damage caused by oxidative

stress have a pivotal role in the causation of metabolic

syndrome and development and progression of CVD and

diabetes [54]. In an uncontrolled study, it was observed that

16 weeks of yogic practices caused a significant decline in

fibrinogen and increase in fibrinolytic activity [55]. In

another non-randomized study of healthy German adults it

was demonstrated that 3-month residential Kriya yoga

program resulted in a significant fall in fibrinogen relative

to controls [56]. These trials suggest that yoga may foster

beneficial changes in the coagulation and fibrinogen system

in healthy adults.

Results of some small studies [42, 45, 46, 57–60] pro-

vide evidence that yoga may reduce oxidative stress in both

healthy populations and chronic insulin resistance-related

disorders. Observed changes in other oxidative stress

indices include increase in antioxidants and antioxidative

enzymes and reduction of free radicals.

Yoga and regression of atherosclerosis

Two randomized trials have shown that the early athero-

sclerosis (as assessed by carotid intimal-medial thickness

cIMT) is significantly reduced by regular practice of yoga/

meditation [37, 61]. Fields et al. showed that after 9-month

Multi Modality Natural Medicine program including TM,

cIMT was significantly reduced. Manchanda et al. [37]

demonstrated that 1-year practice of yoga significantly

reduced cIMT in patients with metabolic syndrome as

compared to controls.

Three controlled studies utilizing coronary angiography

in advanced atherosclerotic coronary heart disease have

demonstrated that regular practice of yoga/meditation with

use of low fat vegetarian diet caused retardation of pro-

gression and/or regression of coronary obstructions as

compared to the usual care control group [43, 62, 63]. In

addition the need for interventional procedures was sig-

nificantly reduced. LDL-c, Tg, body weight, angina and

exercise induced ischemia were also significantly reduced

in the yoga group. All three studies reported excellent

compliance with yoga practices and no side effect were

reported in patients with significant coronary obstructive

disease.

Yoga and secondary prevention

In a recent randomized controlled trial of TM and health

education in Blacks, it has been reported that there was a

48 % risk reduction in primary end point which was

composite of all cause mortality, myocardial infarction and

stroke over a period of 5.4 years [64].

In addition there was significant reduction in systolic

blood pressure and anger expression. This study suggests

that meditation may be useful for secondary prevention of

coronary heart disease.

Yoga and cardiac rehabilitation

Cardiac rehabilitation has been shown to be beneficial in

recovery process after myocardial infarction. Among its

component interventions, evidence suggests that exercise

may have a stronger effect on mortality, while psychosocial

interventions act more on quality of life measures. Yoga

practice leads to similar outcomes as cardiac rehabilitation

(improved physical fitness, stress reduction and lifestyle

change). Yoga has contributed to general well being,

decreased physiological arousal, better sleep and appetite

[65–67]. Yoga, therefore, could provide a useful frame-

work to develop an economical cardiac rehabilitation

programme.

Yoga and smoking

A recent randomized controlled trial has suggested that a

brief training of mindfulness meditation produced a sig-

nificant reduction of smoking by 60 % and also curbed

craving in smokers [68]. These changes were probably

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123

related to improved self-control as suggested by increased

activity in the anterior cingulate and prefrontal cortex in

functional MRI.

Yoga and arrhythmias

A small study (Yoga MYHEART Study) has suggested that

yoga may decrease the arrhythmia burden, anxiety, depression

and improve quality of life in paroxysmal atrial fibrillation,

suggesting that yoga may be useful in some arrhythmias by its

influence on the autonomic nervous system [69].

Possible mechanisms of action of yoga

Although the mechanisms underlying the potential beneficial

effects of yoga on cardiovascular risk profile are not yet well

understood, the observed changes probably occur primarily

through two pathways. First, by reducing activation and

reactivity of the sympathoadrenal system and hypothalamic

pituitary adrenal (HPA) axis and promoting feelings of well

being, yoga may alleviate the effects of stress and foster

multiple positive downstream effects on neuroendocrine sta-

tus, metabolic function and related inflammatory responses;

second, by directly stimulating the vagus nerve yoga may

enhance parasympathetic output and thereby shift the auto-

nomic nervous system balance from primarily sympathetic to

parasympathetic leading to positive changes in cardiac vagal

functions, mood and energy state and in related neuroendo-

crine, metabolic and inflammatory responses.

Limitations of yoga studies

Although yoga/meditation has been found to be useful in

many cardiovascular disease states, there are several limi-

tations of reported studies. Most of the studies have small

sample size and have inconsistencies in baseline; many have

absence of adequate controls and non uniform methodolo-

gies. Meta-analyses of yoga studies have similar limitations.

Larger multicenter randomized studies are needed to confirm

these findings. However as yoga/meditation is a cost-effec-

tive, simple technique without any side effects and hence

could be recommended for primary and secondary preven-

tion of cardiovascular disease and that it can play a primary

or complimentary role in this regard [70].

Conclusion

Yoga is a mind–body technique and meditation is an

important component of yoga. Many studies suggest that

yoga/meditation may be helpful in controlling several risk

factors for coronary heart disease like hypertension, type 2

DM, dyslipidemia, oxidative and psychosocial stress,

obesity and smoking. Yoga/meditation has also been

shown to be beneficial in secondary prevention of CHD

and even in paroxysmal atrial fibrillation. Yoga may even

regress atherosclerosis. However, there are several limita-

tions of the reported studies and larger studies are needed

to confirm these findings.

Conflict of interest On behalf of all authors, the corresponding

author states that there is no conflict of interest.

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