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Yoga-based cardiac rehabilitation offers mixed results after implantation

CHICAGO – A yoga-based cardiac rehabilitation program was safe and improved the quality of life after MI, but failed to provide significant clinical benefits in a randomized trial from India.

Yoga is becoming more and more popular around the world and has the potential to become a low-cost alternative to conventional rehabilitation programs, said study author Dorairaj Prabhakaran, MD, DM, Center of Chronic Hospitals, New Delhi, India. | Medscape Cardiology.

"In the United States, the minority population, women and the elderly do not actually undertake a conventional rehabilitation because they have difficulty, especially the physical exercise component," he said. "So, we can introduce some of the most polite poses, meditation and breathing exercises, which they could consider more acceptable".

The study was presented at a recent scientific meeting at the 2018 Scientific Sessions American Heart Association (AHA) scientific conference.

Researchers at 24 Centers in India randomly delivered 3959 patients within 14 days of M1-14 weeks of Yoga-CaRe or enhanced standard care including three training sessions and leaflets delivered by a nurse or group of cardiac care.

Yoga-CaRe consists of lifestyle education, three health rejuvenation exercises and breathing / mediation training and 15 yoga stops delivered in 13 weeks by trained yoga instructors with self-medicating home practice for the last week.

Three-quarters of the patients showed a ST-segment MI incremental marker and almost a third had hypertension or diabetes or were current smokers. Their mean age was 53.4 years.

There was a high level of modern cardiac care in both arms, noting Prabhakaran, with nearly 60% of patients undergoing transdermal coronary intervention, 98.5% receiving anti-platelets, 84% dual antiplatelet therapy, 93% statins about 50% of angiotensin converting enzyme inhibitors / angiotensin receptor blockers.

At 42 months, 6.7% of the Yoga-CaRe group and 7.3% of controls showed composite primary endpoint death, non-fatal MI, non-fatal stroke and extraordinary cardiovascular hospitalization. The difference failed to reach statistical significance in a prosthesis analysis to be treated (risk ratio [HR], 0.91. 95% confidence interval [CI], 0.72-1.15).

The analysis was inadequate to detect the differences because less than half of the estimated events occurred, Prabhakaran said, who also noted that post-MM care improved in India during the study.

In a protocol-based analysis of 1059 patients who completed at least 10 Yoga-CaRe sessions, the number of primary endpoint events was nearly halved (HR, 0.54, 95% CI, 0.38-0.76, log rank P <.001).

The self-assessed quality of life, measured by the mean change in the 3-month EQ-5D scale, significantly favored the Yoga-CaRe over the controls (10.7 versus 9.2, P = .002).

Patients practicing yoga were more likely to return to their day-to-day activities (P <.001) and to achieve up to six health conditions (P = .04), but it was equally probable with controls to quit smoking (P = .11) or to achieve high drug adhesion (P = .52).

Was He A Fair Comparator?

The invited discussion Vera Bittner, MD, University of Alabama, Birmingham, stated that yoga intervention was well defined but that enhanced standard care interventions had far fewer contacts with study staff.

"This is something that could have influenced quality of life, but also a return to past activity measures, since we know from cardiac rehabilitation settings that staff encouragement can really play an important role in these measurements," he said.

There was also no intervention of physical activity in the control arm, asking whether the observed differences of the group are specific yoga and whether similar effects could be achieved with a home-based walk.

Concerning the generality of the results, Bittner said it was unclear whether it would be translated into MI populations in other settings or in weaker patients, given the young age of the patients, the low percentage of women and the low incidence of cardiovascular events.

Only 53% of yoga intervention raises the question of whether attachment would be worse outside of the clinical trial.

Going forward, Yoga Intervention studies should compare the typical heart restoration in the center or at home, Bittner concluded.

"What we are missing here is a comparison with the traditional protocol based on a cardiac rejuvenation protocol against yoga," said AHA chairman, Donna Arnett, MSPH, PhD, of the University of Kentucky College of Public Health, Lexington. | Medscape Cardiology. "Seeing that the comparison would be a great next step in this research."

Cardiac rehabilitation is one of the best proven based programs available to prevent secondary obstructions for people who are in post MI, but is far too short, he observes.

"I think what we need to understand better now is because we have so low a recruitment of cardiac restoration in our population," Arnett said. "Perhaps yoga would threaten less a population in the post-MI after cardiac restoration using traditional methods, but we still need this comparison."

That said, he added, "In low-income and middle-income countries, this could be an excellent solution."

Having demonstrated the safety and feasibility of yoga in the environment after MI, Prabhakaran said he wants to extend the intervention to heart failure. "The population of heart failure is increasing and a recent study in India showed that 50 percent of patients are dead in five years," he said in an interview.

Regarding whether yoga could be a low-cost alternative and not just an additional remedy for standard cardiac rehabilitation, he added: "It can replace it, but it would be a leap of faith for a country like the United States, who has years of experience with cardiac restoration. "

The test was funded by the Indian Medical Research Council (India) and Medical Research Council (UK). Prabhakaran, Arnett and Vittner did not report any conflicts of interest.

American Heart Association (AHA) 2018 scientific sessions. Abstract 19546. Presented on 10 November 2018.

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