Yoga After Heart Surgery for Stent Placement

by Baxter

Back in the late 60s and early 70s, a new surgical treatment for blocked heart blood vessels was being perfected. Known as coronary artery bypass grafting, it allowed doctors to work around the heart’s own blood vessels that supply the muscle of the heart with oxygen and nutrition when they became dangerously plugged with plaque buildup. Patients that previously would have, most likely, suffered severe or life-ending heart attacks were now being surgically repaired and at least temporarily “cured” of their heart blockages. I say temporarily because doctors like Dean Ornish, MD, noticed that many of these patients who had undergone open-heart surgery would return several years later with new blockages in their new plumbing! Most likely, this was due to the fact that they had not changed their lifestyle and dietary habits. 

As early as 1977, cardiologists started trying to treat the blockages in the heart blood vessels without having to crack the chest open, instead threading a catheter into a large blood vessel in the groin area and guiding it up to the heart and into an individual heart blood vessel. Once at the narrowing area of the blood vessel threatening the patient’s heart, a small mesh scaffold, called a “stent,” was slipped into place and gently expanded to reopen the narrowing. This stent was then left in place. 

All this history gets personal for both Nina and me, as we both have had loved ones undergo stent placement for coronary heart disease in the past year. In my case, my family member had just celebrated his 50th birthday, and with little prior warning or symptoms, had a sudden cardiac event at home that required CPR and electric shock to the chest by the EMTs to restart the heartbeat again. Evaluation at the hospital immediately afterwards showed one heart vessel with a blockage and a stent was put in place right away. Follow-up tests showed no permanent damage to the heart muscle from this heart attack—thank goodness!

It has been found that patients who go through “cardiac rehabilitation” programs following stent placement do better down the road than those that don’t. Cardiac rehab involves progressive aerobic activity on treadmill and stationary bikes while having the heart rhythm monitored, for 30 minutes 3 times a week for 3 weeks, then bumped up to 45minutes, 3 times a week for 3 more weeks. In my family member’s situation, he had been very physically active prior to his event, swimming and golfing regularly, and he was anxious to be able to return to those activities. If yoga had been his thing, I suspect that same desire would have been there. So, what are the recommendations about “return to activity” that could guide you as a yogi if you have to have a stent placed? The NIH has the following post-stent recommendations:

“After a stent procedure, [because of the risk of blood clots causing your open vessel to close,] your doctor will likely recommend that you take aspirin and other anticlotting medicines. Patients are told to avoid vigorous exercise and heavy lifting for a short time after the stent procedure. Your doctor will let you know when you can go back to your normal activities. … However, stents aren't a cure for atherosclerosis or its risk factors. Lifestyle changes may include changing your diet, quitting smoking, being physically active, losing weight, and reducing stress. You also should take all medicines as your doctor prescribes. Your doctor may suggest taking statins, which are medicines that lower blood cholesterol levels.”

Interestingly, there aren’t many other warnings I could find about returning to full activities, such as yoga, and no specific warnings about avoiding certain positions, including inverted yoga poses. In fact, a student of mine had his first of four stents placed for angina, or heart pain, starting at age 67 in 2000. He started doing yoga in 2003, which included regularly practicing Shoulderstand (Sarvangasana) at the wall in his new home yoga practice. He has continued to include it since then. He felt pretty certain he had discussed doing yoga with his family doctor at the time, as well as his heart doctor, and was not given any specific restrictions or warnings about yoga in general. 

I would not suggest that this means you should start a vigorous yoga practice that includes a lot a challenging inversions, but would instead suggest a gradual introduction of yoga over the course of time, just as the cardiac rehab is gradually advanced while monitoring for worrisome symptoms. And certainly engage in a conversation with your heart doctor about their views on the safety of your desired yoga program. Also, keep in mind that even a gentle yoga practice, like the one used in the Ornish Heart studies, has been shown to have powerful effects on long term heart health. So you likely have a wide range of options as to the kind of yoga practice you might restart or start for the first time if you find yourself confronted with a new diagnosis of coronary heart disease. If any of our readers have been given different advice by their docs, please write to us about it.

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Heart Health and Yoga: An Overview

by Nina

The Heart by Henri Matisse*

After three years of blogging, even I, the Editor-in-Chief, can't remember everything that’s on our blog. So because someone close to me has developed heart disease and I want to be able to help him, I’ve been—hahaha—reading through my own blog today. At the same time that I’m trying to see which topics we’ve covered so far (nothing on stents that I can see—paging Dr. Baxter Bell!), I’m also trying to get up to speed on some background information by re-reading some of our older posts. So it occurred to me that while I was educating myself on the topic of yoga and heart health, I should share what I find out with you all. After all, the U.S. Centers for Disease Control says that heart disease is the leading cause of death of in the U.S.

In Shari’s post Yoga for Heart Conditions, she provides an excellent overview of what heart disease is and how yoga can help. She says that she believes that:

“yoga can be so effective for the management of heart disease because it is a holistic health approach that takes into account all of the varied systems of the body —in yoga, the body is part of a greater whole. Yoga is also accessible to all who want to practice, no matter what their physical ability may be. And yoga’s powerful stress management tools, including learning to slow down and breathe deeply, have many beneficial effects on heart health. Several scientific studies have now demonstrated conclusively that learning to breath deeply decreases blood pressure and slows down heart rate by stimulating the parasympathetic nervous system (Relaxation Response) and slowing down the sympathetic nervous system (Fight or Flight Response). And once you learn to become mindful of your breath and of how your body can feel when it is in a relaxed state as opposed to a hyper-arousal state, then conscious, healthy eating is a natural sequel of the yogic approach to health. Finally, learning to move your body (which nourishes all the musculoskeletal, respiratory, lymphatic, and circulatory systems) will help improve heart health.”

In Baxter’s post About Yoga for Heart Health, he wrote about how yoga practices help to maintain or improve circulation in the cardiovascular system, which is essential for heart health. He concludes that post by saying:

"Yoga, therefore, can be said to improve circulation by improving blood flow and the return of lymphatic fluids to the heart, reversing the impact of chronic stress on circulation, lowering blood pressure, slowing down or reversing atherosclerosis, improving the heart rhythm and improving overall heart health."

In Baxter’s post Cortisol and Good Health, he focuses in particular on the relationship between chronic stress and health problems, including heart disease. He says:

"But if you are either under constant stress, or your mind is prone to brooding about the past or anxious musings about the future or even negative assessments about the present moment, your adrenals interpret this as an actual stressful event occurring right now, and cortisol gets released into your system. So cortisol levels remain high in the blood stream for greater periods of time, which can result in swelling of the gland itself, and an increased chance of the following negative effects: loss of immunity secondary to shrinkage of lymph glands, increased risk of stomach ulcers, increased risk of hypertension, heart disease and other vascular disorders, excess sugar in the blood stream and more chance of developing diabetes."

While we in the yoga community all know that yoga can help to improve circulation and reduce stress (see The Relaxation Response and Yoga), Baxter also recently posted Yoga and Heart Health: Newest Study about a scientific meta-analysis study Effects of yoga on cardiovascular disease risk factors: A systematic review and meta-analysis, which concluded:

"This meta-analysis revealed evidence for clinically important effects of yoga on most biological cardiovascular disease risk factors. Despite methodological drawbacks of the included studies, yoga can be considered as an ancillary intervention for the general population and for patients with increased risk of cardiovascular disease."

Baxter has even designed two different yoga sequences for heart health, both short and accessible practices.

The Inverted Heart Health Sequence includes inverted poses because they can have several immediate and long-term influences on your heart and circulatory system. Inversions put your body in a position to take advantage of gravity to assist in venous return to your heart—you flip upside down and gravity pulls the blood back toward your heart and head! They can also have a quieting effect on your nervous system, encouraging a shift from Fight or Flight mode to Rest and Digest mode. Your heart muscle needs both exercise and rest, so a good combination of effort and relaxation in your practice will give your heart a more balanced experience.

The Cardiovascular Heart Health Sequence includes:

• Dynamic Yoga Sequences. Linked sequence of poses that move fairly quickly, such as Sun Salutations, gradually warm up your body and your cardiovascular system, both strengthening and stretching the muscles and connective tissue that your body’s blood vessels pass through, both exercising your heart and encouraging more efficient flow through the piping of your system.
• Static Poses. Poses that you hold for longer periods increase what is known as the “work load” of your heart, providing a different kind of exercise and challenge for your heart. Those with high blood pressure and diabetes will have to approach these poses with  caution and work into the holds very gradually, preferably under the guidance of an experienced teacher. 
• Gentle Inversions and Restorative Poses. These poses quiet and rest your cardiovascular system and your heart, which is equally important to testing and stressing your system. They allow your heart and nervous system to quiet, and as a result can nicely lower your blood pressure, heart rate and breathing rate.
• Pranayama and Meditation Practices. These practices support the effects of the inversions and restorative poses.

If chronic stress is a problem, see The Relaxation Response and Yoga for an overview of how yoga helps with stress and a list of techniques to choose from. We also have many posts on insomnia (see Five Tips for Better Sleep, for example). Finally, if you’re struggling with poor eating habits, see Yoga for Healthy Eating. 

I'll be giving my loved one private lessons, starting with initial lessons on managing the stress related to realizing you have the disease and coping with surgery and recovery, and I'm sure I'll have more to say about yoga for heart disease as I learn more about it myself.

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Featured Sequence: Dynamic Cardiovascular Health Practice

by Baxter

Heart health should be at the top of almost everyone’s priority list for the simple fact that cardiovascular disease is the number one cause for death in the US each year. More people will die this year from heart disease than will die from all the cancers combined! So, keeping your heart healthy can translate into a longer, more vital life for many of us.  The practice I am sharing with you today assumes that you do not have any active heart problems at this time. If you are not sure of your heart status, it would wise to visit your primary care doc to have a good physical exam and ask you doctor if you have any limitation on your physical activity. If you get the green light, than this practice should be both beneficial and safe for you to do. 

There are 4 basic components to this practice: 

Dynamic Yoga Sequences. Linked sequence of poses that you move fairly quickly, such as, the Sun Salutations, gradually warm up your body and your cardiovascular system, both strengthening and stretching the muscles and connective tissue that your body’s blood vessels pass through, thus exercising your heart and encouraging more efficient flow through the piping of your system.

Static Poses. Poses that you hold for longer periods increase what is known as the “work load” of your heart, providing a different kind of exercise and challenge for your heart. Those with high blood pressure and diabetes will have to approach these with poses caution and work into the holds very gradually, preferably under the guidance of an experienced teacher.

Gentle Inversions and Restorative Poses. These poses quiet and rest your cardiovascular system and your heart, which is equally important to testing and stressing your system. They allow your heart and nervous system to quiet, and as a result can nicely lower your blood pressure, heart rate and breathing rate.

Pranayama and Meditation Practices. These practices support the effects of the inversions and restorative poses.

Let’s get started!

Dynamic Cardiovascular Practice

1. Modified Sun Salutation (Surya Namaskar): Practice a Mini Sun Salutations as described at Featured Sequence: Mini Sun Salutation. As you stand in Mountain pose at the front of your mat, take a moment to check in with your body and your mind, setting an intention for your heart practice. Since this part of the practice will likely get the heart rate up a bit, feel free to do several rounds—anywhere from two to six.

2. Extended Side Angle Pose (Utthita Parsvakonasana): From Mountain pose, step your feet wide apart, turn your right foot and leg out 90 degrees and kick out your back heel an inch or so. Bring your arms up parallel with the floor and bend your front knee. Then side-bend your hips and torso over your right leg and put your right hand on a block on its highest height, placed snug up against the outside of your front shin. Swing your top arm up and overhead, completing the side angle from your back leg through your torso and into your top arm. Push down firmly into the block with your bottom hand, and feel your right shoulder blade firm into your chest and slightly down toward your waist. Reach your top arm and shoulder blade strongly forward towards your fingers. Since this is a static, held posture that will increase the workload of the heart, aim to stay in it for at least six breaths, and work your way up to 90 seconds over time. Inhale as you come up, relax your arms at your sides and repeat on the second side. 

Note: you can always create a “dynamic” version of any of the standing poses, moving into and out of the pose with your breath, as a warm up to doing it statically.

3. Side Plank Pose (Vasithasana): on the Wall and on the Floor: Although the classic version of this pose (Vasthithasana) is done on the floor, the wall version of the pose is much more accessible because you stand on the floor and bear less weight on your arm. In addition to it being an upper body strengthener, it also opens up the area of the chest that surrounds the heart! 

To come into the pose, start with your right side to the wall, and reach your right arm out to your side, parallel with the floor, and place your palm on the wall with your fingers pointing up. Engage your right shoulder blade into your chest wall and down slightly towards the right side of your waist. Then, step both feet out away from the wall, until your right foot is positioned directly under your left shoulder. If your balance is good, try bending your left knee and bringing your left foot into Tree pose. Then take your left arm up and overhead, reaching strongly towards the wall with your left arm and shoulder blade, aligning it like the top arm in Extended Side Angle pose. Stay for 6 breaths and work up from there. Repeat on the second side.

If you are feeling strong, try coming into the full pose from Downward-Facing Dog pose. From Downward-Facing Dog, swing your shoulders forward almost into Plank position while keeping your hips lifted. Make your right arm stronger by contracting the muscles of the arm to the bone, and tip your heels to the right, bringing the outer edge of your right foot and the inner edge of your left foot to the floor, with your feet slightly apart. Turn your chest away from the floor and bring your left hand onto your left hip. Since this takes a lot of strength, stay just few breaths at first, and gradually add more time with more practice. To come out, swing back into Downward-Facing Dog pose and repeat the pose on the second side. Afterward, rest in Child’s pose a few breaths.

4. Locust (Salabhasana):  See Locust Pose for instructions on how to do the pose dynamically. Practice the pose dynamically as a way to warm up for the full, static version. In the full, static version, you will lift both legs, your chest and your head, and hold the pose for 10 seconds to start. Gradually add more time until you can do a 30-second hold. Rest for a few breaths before moving on. Because this is a backbend, it will open your chest around your heart and lungs.

5. Bridge Pose (Setu Bandha): Start in Constructive Rest position (on your back with knees bent and heels about four inches from your hips) with a block close by, and establish the normal, slightly arched shape of your lumbar spine. Then lift your hips straight up as you push down into your feet, like an elevator going up a few floors, maintaining the neutral arch of your lower back. Once in Bridge pose, bring some focus to your arms. Press the upper back of your upper arms (right where your arms meet the shoulders) firmly down into the floor while actively lifting the lower tip of your breast bone up to the sky. Then press your arms—which are lengthening towards your feet—firmly down into the floor as well. This will begin to encourage extension of your shoulder joints. 

Now, grab the block and place it under your pelvic bones, positioning it where a belt would be if you were wearing slacks, at whatever height feels good for your body. Stay for 1-3 minutes. This supported, partial inversion will encourage the benefits described above. To come down, lift your hips slightly off the block and move the block out of the way, and then lower your hips straight down, like an elevator returning to the lobby floor. Then, gently roll to your side and come up to sitting.

6. Simple Seated Twist (Sukasana Twist): Take whatever props you need to sit comfortably, from a folded blanket to a block or even a chair (see Learning to Sit on the Floor, Part 2). When you are comfortably seated, inhale and encourage an upward lift through your spine. Then, as you exhale, turn your chest and upper belly to the right, bringing your right hand to the floor behind you and your left hand to your right knee. Try to create the twist from the center of your body and allow your arms to simply support the shape. Stay for just a few breaths, and then release to center and repeat on the second side.

7. Pranayama: In your seated position (see Learning to Sit on the Floor, Part 2), or if you are fatigued, in a supported reclining position, turn your attention to your relaxed breathing pattern. At this point in your practice, it’s time to encourage relaxation and quieting of the heart and nervous system. So working with the gentle lengthening of your exhalations is a simple and excellent way to support that goal. In this breath practice, the classic ratio of the length of your inhale to exhale is 1:2, which could be a one-second inhalation and a two-second exhalation or a two-second inhalation and a four-second exhalation—you get the idea. The key is to keep your breathing relaxed so you are not over-efforting.  I like to do a set number of repetitions, such as six rounds or twelve rounds. Then let your breath return to its natural length and depth, and notice how things feel internally. 

8. Easy Inverted Pose (Viparita Karani modified): Finish your practice with this partial inversion. See Featured Pose: Easy Inverted Pose for complete instructions. While in the pose, focus your attention on the area of your heart, visualizing your heart as strong and steady, and also relaxed and rested. Try keeping your attention in this general area as you rest for five to ten minutes before returning the your day.

Yoga and Heart Health: the Newest Study

by Baxter

In the spirit of keeping up with all the new developments in the scientific study of yoga, I’d like to share some information about a new study on yoga and heart health that came out last week. Last Tuesday, the day I went live on yogauonline.com with my own lecture series on heart health, they ran a story about a new study that reviewed a bunch of previous studies looking at yoga’s impact on various factors related to heart disease. 

Since I did not have adequate time to read over the entire study that day, I finally got to it the is week and felt it was worth letting you all know what the researchers found. First off, this is one of those studies where the researchers did not do their own new research on yoga for heart health, but instead they looked back at the work of other studies and tried to put all the data together to get a better overview of what has been studied and found so far. We call these kinds of studies “meta-analysis.” The title of the study Effects of yoga on cardiovascular disease risk factors: A systematic review andmeta-analysis reflects this. The authors looked at 44 studies that fall into the category of “Randomized Controlled Trials” (RCT). This is a kind of study design that aims at limiting the amount of “bias” that the original researchers might have had, therefore, limiting the chances of the researchers stacking the deck in favor of their desired outcome—which in this case would be that yoga is helpful for addressing heart disease. We’ll come back to this in a bit.

The study appeared in the International Journal of Cardiology, and reviewed the 44 RCTs that had been done between 1989-2013 from a variety of countries around the world—almost half were from India, 8 were from the US, and an additional 9 countries represented the remaining studies. Some looked at healthy individuals, some looked at people with diabetes, a known strong risk factor for developing heart disease, and some looked at people who had other risk factors for developing heart disease, like those with high blood pressure, obesity, or high cholesterol, to name a few. Twenty of the studies mentioned the “style” of yoga that was used in the study, with 7 studies calling it “hatha” and the other 13 naming styles like Iyengar, Anusara, and 5 others.

The conclusions the authors made as they analyzed and reviewed all of the information in these 44 studies is that a regular yoga practice can help reduce many of the leading risk factors for heart disease and strokes. To quote directly: 

"This meta-analysis revealed evidence for clinically important effects of yoga on most biological cardiovascular disease risk factors. Despite methodological drawbacks of the included studies, yoga can be considered as an ancillary intervention for the general population and for patients with increased risk of cardiovascular disease." 

The italics are mine. This seems like great news! But before we get too excited, I want to address “ancillary intervention” and “methodological drawbacks”.

Ancillary intervention can refer to treatment options that can be done in an outpatient setting, often in someone’s home. This fits in nicely with our focus here at YFHA on developing home practices for specific goals. An ancillary intervention could also imply something added onto some other primary treatment or preventive actions, presumably more mainstream ways of addressing heart disease risk factors, like taking lipid lowering medications in the setting of high cholesterol. And that may be a reasonable recommendation if we consider the multi-pronged approach that Dean Ornish’s studies used to improve those with coronary artery disease via his Lifestyle Modification Program. Recall that in that setting, they used dietary changes, daily walking program, a daily one-hour yoga/relaxation/breathwork/meditation practice and group support meetings all together to demonstrably change the course of that disease.

The more worrisome feature of the study—the methodological drawback—is that the authors readily admit that most of the studies are not up to snuff when it comes to being scientifically rigorous studies. This means that unlike most studies sponsored by institutions like the National Institutes of Health (NIH) or studies that appear in our most prestigious medical journals, the methods of these particular studies may not up to the highest standards the authors (or I) would like to see. The authors strongly express the opinion that future research must be much better designed in order for us to have more confidence in the results that are reported. To balance out their concern over the quality of the studies, they do mention that due to the “apparent” safety and effectiveness of yoga, it can still be recommended as an additional treatment intervention to other accepted ways of addressing the treatment of risk factors for heart disease. Those specifically cited beneficial effects were on blood pressure, heart rate, respiratory rate, blood cholesterol levels, abdominal obesity and insulin resistance.

So, for us, this is some mix of good news and some lingering uncertainty about the quality of past studies. I hope these sorts of big reviews will start to result in better-designed studies in the coming years. Bottom line for all of us is that a regular yoga practice could be very helpful in lowering our chances of developing heart disease and strokes over time. If you want to learn more about my recommendations on the nuts and bolts of designing your home practice for heart health, consider joining me this evening for Part 2 of Yoga for HeartHealth. 

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Friday Q&A: More About Yoga for Heart Health

Leveil du Coeur by William-Adolphe Bouguereau

Q: Baxter, in your recent post Yoga for Heart Health and Circulation, you mentioned that you were working on an online program on yoga for heart health. When will that be available and where can I find it?

A: Thanks for asking! The online course will be available on yogauonline.com on Tuesday, April 1 and Tuesday, April 8,  2014, 5:30pm Pacific / 8:30pm Eastern. To get an early start, you can download a free interview with me on this topic that is available now via this link. Then, if you wish to sign up for the upcoming webinar, you can do so here.

I hope you find the information I'm presenting on this important topic helpful!

—Baxter

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