Yoga-Based Cardiac Rehabilitation Offers Mixed Results After MI

CHICAGO – A yoga-based cardiac rehabilitation program was safe and improved the quality of life after myocardial infarction (MI), but did not provide significant clinical gains in a trial randomized conducted in India.

Yoga is gaining popularity around the world and could become an inexpensive alternative to conventional rehabilitation programs, said study author Dorairaj Prabhakaran, MD, DM, Chronic Disease Control Center, New Delhi, India. theheart.org | Medscape Cardiology.

"In the United States, the minority population, women and the elderly do not adopt conventional re-education because they find it difficult, especially with regard to physical activity," he said. declared. "So we can present some of the sweetest poses, meditation and breathing exercises, that they might find more acceptable."

The study was presented at a last-minute scientific session here, during the 2018 scientific sessions of the American Heart Association (AHA).

Investigators from 24 centers in India randomly assigned 3959 patients within 14 days of acute MI at 14 weeks after Yoga-CaRe intervention or enhanced standard care including three educational sessions and printed pamphlets delivered by a nurse. or a cardiac care team.

Yoga-CaRe included a lifestyle education, three health regeneration exercises, breathing / mediation training and 15 yoga postures for 13 weeks by qualified yoga instructors, with personal practice at home. during the last week.

Three-quarters of patients had ST-elevation MI and almost one-third had hypertension or diabetes or were currently smokers. Their average age was 53.4 years old.

According to Prabhakaran, nearly 60% of the patients underwent percutaneous coronary intervention, 98.5% received antiplatelet drugs, 84% a double antiplatelet therapy, 93% statins and about 50% angiotensin converting enzymes. inhibitors / blockers of angiotensin receptors.

At 42 months, 6.7% of the Yoga-CaRe group and 7.3% of controls had the composite primary endpoint of death, non-fatal myocardial infarction, stroke. nonfatal and emergency cardiovascular hospitalization. The difference did not reach the statistical significance in an intention-to-treat analysis (risk ratio [HR]0.91; 95% confidence interval [CI]0.72 – 1.15).

The analysis was insufficient to detect the differences as less than half of the estimated number of events occurred, said Prabhakaran, who also noted that post-MI care has improved in India during the study.

In a per protocol analysis of 1059 patients having completed at least 10 Yoga-CaRe sessions, the number of primary endpoint events was almost halved (HR, 0.54, 95% CI). %, 0.38 to 0.76, rank of the log P <0.001).

The self-rated quality of life, as measured by the mean change in EQ-5D visual analog scale score at 3 months, clearly favored the Yoga-CaRe group compared to controls (10.7 vs. 9.2 ; P = 0.002).

Patients who practiced yoga were more likely to resume their daily activities before the heart attack (P <0.001) and reach up to six states of health (P = 0.04) but were just as likely as the controls to quit (P = .11) or to achieve high adhesion to the drug (P = 0.52).

Was it a fair comparator?

Vera Bittner, MD, University of Alabama in Birmingham, explained that the yoga intervention was well defined, but that the standard improved care intervention had had much less contact with the staff of l & # 39; study.

"This is something that could have affected the quality of life and the return to previous activities, because cardiac rehab centers know that staff incentives can really play an important role in these measures," he said. she declared.

There was also no physical activity in the control group, which raises the question of whether the group differences observed are specific to yoga and whether similar results could be obtained with a home walking program.

As for the possibility of generalizing the results, Mr Bittner pointed out that it was difficult to know whether they would be translated for ID populations in other contexts or for patients more sick, given the young age of patients, the low proportion of women and the low rate of cardiovascular events.

The membership in the yoga intervention of only 53% also raises the question of whether membership would be worse outside the clinical trial setting.

Bittner concluded that intervention studies in the field of yoga will now have to compare standard cardiac rehabilitation at the center or at home.

"What we missed here is a comparison with our traditional protocol of cardiac rehabilitation and yoga based on scientific evidence," said Donna Arnett, former chair of the AHA, MSPH, PhD, College of Public Health from the University of Kentucky, Lexington, theheart.org | Medscape Cardiology. "Seeing this comparison would be an excellent step in this search."

Cardiac rehabilitation is one of the best programs available to prevent secondary infarcts in post-MI people, but it is largely underutilized, she observed.

"I think what we need to understand better now is the reason we have so little use of cardiac rehabilitation in our population," Arnett said. "Maybe yoga would be less threatening to a post-MI population than cardiac rehabilitation using traditional methods, but we still need that comparison."

That said, she added, "In low- and middle-income countries, this could potentially be a great solution."

Having demonstrated the safety and feasibility of yoga after ID, Prabhakaran said he wanted to expand his intervention to heart failure. "The heart failure population is increasing and a recent study in India has shown that 50% of patients have died in five years," he said during an interview.

As to whether yoga could be an inexpensive alternative rather than simply an adjunct to conventional cardiac rehabilitation, he added, "He can replace it, but it would be a leap of faith for a country like the United States to experience cardiac rehabilitation. "

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

Scientific Sessions of the American Heart Association (AHA) 2018. Abstract 19546. Presented on November 10, 2018.

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