Abstract
Effective therapy for patients with chronic cardiac failure (CCF) entails significant lifestyle modifications as well as often complex pharmaceutical regimes to alleviate symptoms, which, however, do not actually cure many patients. The gradual loss of cardiac function is impeded but not halted by such complicated pharmacological therapy, which primarily includes angiotensin-converting enzyme inhibitors, beta-blockers and diuretics, and sometimes digoxin, aspirin, warfarin, and anti-arrhythmic agents. Patients may be advised to track their weight and modify their diuretic prescription accordingly to avoid fluid overload or dehydration as part of the treatment plan. Non-pharmacologic treatment options are routinely integrated to improve the management of somatic complaints. Yoga and specialized breathing exercises seem to help CCF patients improve their cardiorespiratory and autonomic system function, and also their quality of life. We present the evidence.
Keywords
Introduction
With an ageing population, the prevalence of chronic cardiac failure (CCF) is expected to increase. 1 The lowest rates are found in SubSaharan Africa. 2 Women >80 years of age have a significantly greater prevalence than males of the same age. 3 CCF is responsible for c. 0.5 to 1.8 million admissions annually in India and is one of the leading medical causes of admission at the early age of 53 years, 3 in contrast to USA and Europe where it becomes the leading cause only at 69 years. The mortality of CCF in India is 10% to 30.8% against 4% to 7% in rich countries. Estimates, based both on data of established risk factors for CCF, suggest that the total burden in India is >2 to 5 million with an estimated prevalence of 2 to 3 per 1000.4,5
The use of complementary medicine in treating CCF patients needs further investigation better to understand its role. Behavioural coping habits such as mindful meditation, coping skills, and support group discussion are known to reduce anxiety and depression. 5 A systematic review of randomized controlled trials of mind-body interventions such as tai chi, yoga, and meditation on heart failure demonstrated small-to-moderate positive effects on both objective and subjective outcomes. 6 However, the mechanism through which these exert their action remains unknown. As well as lowering morbidity and mortality, such techniques appear to enhance both the quality of life and exercise tolerance.
Yoga is a non-pharmacological intervention of breathing exercises that helps improve cardiorespiratory and autonomic system function by restoring inspiratory muscle training and boosting respiratory muscle strength and endurance, both of which are reduced in CCF patients. 6 This boosts oxygen uptake (VO2), functional capacity, and exercise-induced respiratory responses. 6
Meditation has been proven to relieve depressive symptoms, reduce the need for social support, and improve biophysical factors and quality of life in chronic illness.
Methods
Meditation is one of the most well-established, widely used, and pervasively researched psychotherapy techniques. 7 Various methods and approaches exist depending on the idea or notion one wishes to accept or follow. 8 Exercise components may or may not be incorporated into these meditation techniques. 8 Mediation, according to Walsh and Shapiro, 7 ‘refers to a family of self-regulation practices that focus on training attention and awareness’. Tai chi and yoga are two examples of similar intercorrelated meditation techniques that include some form of exercise element. Seated meditation approaches include mindfulness, transcendental, and compassionate meditation. 8
Mindful meditation, originating from Eastern Buddhist meditation practice, which was at the epicentre of Buddha's teaching for over 2500 years, was introduced to the West in the 1960s.9,10 It is a psychological procedure based on relaxation, mental training, and psychological distress reduction techniques and has a wide range of applications in health care.9,11 By controlling attention on purpose, focusing on the present moment, and avoiding making judgements, 12 increased awareness of inner thoughts, emotions, and body sensations are promoted. 12 This is thought to minimize symptom discomfort and enhance overall well-being. 13
It also stimulates the prefrontal and anterior cingulate cortex, and electroencephalography indicates a substantial rise in alpha and theta activity. An eight-week programme taught in a classroom setting combines breathing and yoga techniques. 11
Discussion
Yoga has gained immense popularity and appeal.14–16 It is a traditional Indian methodology that involves practising specific postures, breathing control, and meditation. 17 Yoga is effective in enhancing delayed recall of spatial information and verbal memory, 18 lowering planning and execution time, 19 and cognitive processes 20 in adults. 17
Yoga has the potential to benefit cardiac rehabilitation.14,21 However, there is limited information on the evidence. Breathing, relaxation, and meditation are three components of yoga that lead to decreased chemoreflex response to hypoxia and hypercapnia, leading to superior baroreflex sensitivity and a lower heart rate variability.14,22,23 Lower blood pressure can be achieved by reducing sympathetic activation and improving baroreflex sensitivity, which has a substantial influence on heart failure and other cardiovascular illnesses. 14
A low-intensity yoga programme studied peak cardiovascular capacity, inflammatory markers such as interleukin-6, high sensitivity C-reactive protein, and extracellular-superoxide dismutase, and quality of life in a group of patients with CCF, 14 and showed a significant improvement. 14
Yoga may be defined by multiple ‘pranayama’ techniques. It is suggested that breathing, meditation, and relaxation techniques may increase parasympathetic activity, decrease sympathetic activity, and improve baroreflex sensitivity.
The breathing exercises (pranayama) are known to produce various physiological changes in patients with different diseases and healthy individuals. 24 These have been reported to reduce the signs of oxidative stress, improve autonomic functions, and treat a range of stress-related disorders. 25 Pranayama helps control and prolong the breath results 26 improving oxygen saturation, increasing cardio-vagal 27 baroreflex sensitivity, and reducing blood pressure.
Several pranayama techniques are used; they incorporate Ujjayi, which is described as complete normal breathing with both nostrils, Anuloma-viloma meaning alternate breathing; Sheetali tongue breathing; Sitkari teeth breathing and finally, Bhramari pranayama sound breathing. After following pranayama techniques, participants are recommended to follow meditation and Shavasana (relaxation) techniques (Figure 1(a) and (b)).
Ujjai pranayama: contraction of glottic muscles is paired with slow breathing. The resistance breath is performed by inspiration and expiration at different rates and ratios. The subject sits comfortably, keeping the eyes closed and back erect and rigid. Then, slow, deep inspiration is followed by slow deep expiration with breath-holding in between. The cycle is repeated for 5 to 10 min (Figure 2).
24
Anuloma-viloma pranayama: closure of alternate nostrils whilst breathing in a comfortable sitting position after exhaling deeply. The right hand is used with bent index and middle fingers resting against the palm. The thumb is used to close the right nostril, and the fingers are used for the left nostril over a period of 5 to 10 min. The process is then reversed (Figure 3(a) and (b)).
28
Sheetali pranayama: sitting in a comfortable position, with closed eyes, inhaling through the tongue folded into the form of a tube, and exhaling slowly through both nostrils. This procedure must be done after the proper training by a yoga instructor. Ten rounds are followed by 2 min of rest (Figure 4).
29
Sitkari pranayama: sitting comfortably on a cushion or chair with the spine straight. With upper and lower teeth brought together, inhaling as deeply as possible and then exhaling through the nostrils, with the mouth closed. This is repeated 5 to 10 times with 2 min gap in between for 10 min (Figure 5).
25
Bhramari pranayama (also known as humming bee breathing): sitting in a comfortable position with closed eyes, inhaling slowly and deeply through both nostrils and exhaling the same way with the thumbs occluding both ears, simultaneously chanting, ‘Ohm or A U Mm’ together with a humming nasal sound, repeating this for 5 to 10 cycles (Figure 6).
30
Shavasana. (a) part by part relaxation. (b) complete body relexation.
Ujjayi pranayama.
Anuloma-viloma pranayama. (a) Right hand thumb closing right nostril and inhaling from left nostirl. (b) Right hand finger closing the left nostril and allowing exhalation from right nostril.
Shitali pranayama.
Sitkari pranayama.
Bhramari pranayama.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
