Yoga CaRe: When Evidence-Based Science Meets Ancient Wisdom

Yoga can be vaguely defined as group of ‘mind-body’ exercises. Though exact timing remains debatable, origin of yoga can be traced back to more than 3,000 years ago when it was first mentioned in ancient Indian text ‘Rigveda’. Yoga is among one of six fundamental ‘Darshanas’ of Hindu philosophy. Various yoga practices were integral part of Indian sages’ routine, who taught and propagate various yogic practices across ancient India.

In western society, yogic practices involving ‘Asanas’ (stretching/body posture), ‘Pranayama’ (breathing exercise), and Meditation have become popular as mean of reducing stress and improving physical well-being.  Several small studies have reported beneficial effects of yoga in primary and secondary prevention of cardiovascular disease (CVD) [1-3]. Yoga based cardiac rehabilitation program post coronary artery bypass graft surgery has been reported to be associated with improvement in left ventricle function, lipid profile, stress reduction and quality of life [1, 2]. However, studies reported beneficial effects of yoga have been limited by small sample size, lack of adequate control, and non-uniform methodologies. Thus, utility of yoga based rehabilitation program in patients with pre-existing CVD remains uncertain.

Against this background, group of Indian physicians conducted a multi-center randomized controlled trial, to evaluate effectiveness of yoga-based cardiac rehab (yoga-CaRe) in patients with acute myocardial infarction. Dr. Dorairaj Prabhakaran from Center for Chronic Disease Control (New Delhi, India) presented the results of this study in a late-breaking science session at the American Heart Association 2018 Scientific Sessions. Study randomized 3,959 patients with acute MI patients from 24 Indian centers to 14 weeks of either Yoga-CaRe or enhanced standard care (ESC). Patients in Yoga-CaRe group underwent 13 sessions of yoga (3 health rejuvenating exercises, 15 postures, 5 breathing techniques & 5 meditative techniques) under trained yoga instructor guidance. ‘Asanas’ (body posture) in Yoga-CaRe group were carefully selected to avoid significant tachycardia.  ESC was comprised of 3 educational sessions (before discharge from the hospital and subsequently at weeks 5 and 12) and printed leaflet delivered by nurse or another member of cardiac care team either individually or in groups to avoid contamination. At 42-month follow up, compared to ESC, patients in Yoga-CaRe had numerically fewer composite endpoint events (death, nonfatal MI, nonfatal stroke, or emergency cardiovascular hospitalization) in the intention-to-treat analysis; however this difference was not statistically significant. The secondary endpoint of self-rated quality of life, and rate of patient return to pre-infarct daily activities were better in Yoga-CaRe group at three months. As per Dr. Prabhakaran ‘.. it (yoga) improve quality of life and made patient return to pre-infarct activities as quickly as possible….wherever people adhere to yoga i.e they attend more than 10 sessions there was reduction in composite end point particularly in death..’

Despite been a class I recommendation cardiac rehabilitation remains highly underutilized in post MI patients.  Situation is even worse in underdeveloped countries where structured cardiac rehabilitation post MI is almost nonexistent due to limited resources. In this context, results of this study are very relevant as yoga is relatively inexpensive and can be delivered by trained instructor to group of patients without further straining already overburden health care system. As pointed out by Dr. Prabhakaran ‘Yoga is feasible, and it can be ambitiously scaled up in term of cardiac rehabilitation..’. This could have far reaching benefits in low- and middle-income countries with limited health staff and resources, and high CVD burden.

However, due to lack of standardized physical exercise component in control arm of Yoga-CaRe trial, it remains unclear if yoga offers any additional benefits over traditional exercise performed for equal duration. Further, Yoga-CaRe enrolled relatively younger patients (mean age ~53yr) and predominately males (>85%). Thus, potential role of yoga in post MI elderly and females patients remains unexplored. Future, large-scale studies addressing these limitations and evaluating yoga based cardiac rehab in other CVD like heart failure would be useful in testing utility of these age old ‘mind-body’ exercises in modern world.



  1. Raghuram N, Parachuri VR, Swarnagowri MV et al. Yoga based cardiac rehabilitation after coronary artery bypass surgery: one-year results on LVEF, lipid profile and psychological states–a randomized controlled study. Indian Heart J. 2014 Sep-Oct;66(5):490-502.
  2. Amaravathi E, Ramarao NH, Raghuram N et al. Yoga-Based Postoperative Cardiac Rehabilitation Program for Improving Quality of Life and Stress Levels: Fifth-Year Follow-up through a Randomized Controlled Trial. Int J Yoga. 2018 Jan-Apr;11(1):44-52.
  3. Yeung A, Kiat H, Denniss AR, Cheema BS et al. Randomised controlled trial of a 12 week yoga intervention on negative effective states, cardiovascular and cognitive function in post-cardiac rehabilitation patients. BMC Complement Altern Med. 2014 Oct 24;14:411.
  4. Prabhakaran D, et al “Effectiveness of a yoga-based cardiac rehabilitation (Yoga-CaRe) program: a multi-centre randomised controlled trial of patients with acute myocardial infarction from India” AHA 2018.



What Do Patients Want To Know About Their Disease?

As the chair of the Heart & Lung patient organization in Sweden, I organize monthly meetings with patients and provide lectures with information about their diseases.

A year ago I was at a conference called EuroHeartCare (Conference for Cardiovascular Nurses and Allied Professionals) and at that conference a physiotherapist asked me how I know what kind of lectures these patients want. She asked if I actually asked them. Unfortunately, I had to answer that I decided myself what kind of lectures these patients received and I never asked them what they wanted to know. The Physiotherapist told me that they started a research called learning cafés, where they ask patients what information they want. Based on these answers they invited professionals to answer those questions.

When I came home, I was inspired and sent all the patients in the organization an invitation to come with their significant others and discuss what kind of questions they have on their diseases and what kind of information they would like.
I have to admit, I thought I knew the questions they had, but I couldn’t have been more wrong. To my surprise, there was need for other information about heart failure, then I provided. The biggest questions were about sleep, food, and physical activity:
“I am sleeping very bad, what can I do to improve this?”
“If I am sleepy during daytime, what is the best thing to do?”
“Is it true that patients with heart failure are more tired than elderly without this disease?”
“Is it possible to change my diet, so I am not that tired?”
“Is there medication to help with my endurance?”
“I heard that I can’t eat broccoli or strawberries, is this true?”
“Is it okay to take diuretic pills later in the evening if I go out for dinner with my family, without going to the bathroom that often?”
“Is it true that I can’t drink more than 2 liters a day?”
“Is there a limit in how much kcal I can eat a day now I have heart failure?”
“Is it only safe to go to the gym (rehab) or walk to be physically active, or are there more ways of physical activity that are safe?”
“If I am short of breath, how do I know if this is because of my heart failure or because of my COPD?”
Based on these questions, I now invited researchers to the organization to answer those questions and we organized different ways in being physically active, like exergaming (being physically active by a video game) and medical yoga. For the next meetings, I sent out the program and asked if the patients could give suggestions to add in the program. Patients would like to add aqua jogging, have exergaming bowling competitions between organizations, add groups of Nordic walking and they are enthusiastic on trying medical yoga through an app at home (and the oldest participant is 94 years old!). Additionally, they would like to have wine tastings, trips to castles, trips to a museum and have dinners together (we just had a Valentine’s lunch).

patient playing bowling on a computer - example of exergaming 

Patient playing bowling on a computer
The bottom-line of this little blog is that I think that sometimes as researcher we should sit back and ask patients what they would like to know, what is important for them, instead of us deciding for them.

Furthermore, I believe that in able to provide person-centered care, patients and their significant others should co-design interventions and be included in the evaluation of interventions.

Leonie Klompstra Headshot
Leonie Klompstra is a Nurse Scientist at the Linköping University in Sweden. Her primary focus is on heart failure and rehabilitations.