Editor's Note: Based on Lakkireddy D, Atkins D, Pillarisetti J, et al. Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: the YOGA My Heart Study. J Am Coll Cardiol 2013;61:1177-82.

Introduction

Atrial fibrillation (AF) is an increasingly prevalent cardiac arrhythmia, associated with increased morbidity and mortality, as well as substantial health care costs.¹ Patients with AF have an increased incidence of depression and anxiety, presumably due to impairment in quality of life (QoL).^{2, 3} Yoga has been shown to reduce the symptoms of depression and anxiety and result in QoL improvement.⁴ In this context, the YOGA My Heart Study (NCT00798356) investigated the effects of yoga training on AF burden, QoL indicators, anxiety, and depression.⁵

Methods

The YOGA My Heart Study was a single center, prospective, self-controlled, pre-post cohort study. The study enrolled patients with paroxysmal AF between 18 and 80 years of age. Patients were considered ineligible if they had a history of AF ablation within three months, life expectancy <1 year, advanced heart failure, contraindication for yoga training, or if they had practiced any form of yoga in the preceding six months. Each patient in the study served as his or her own control. The study started with a three-month control period, followed by a three-month yoga intervention phase, during which all patients underwent structured Iyengar yoga training at least twice weekly. During the study period patients were instructed to record, using a symptom diary and a cardiac nonlooping event monitor, all episodes they felt that were consistent with symptoms of AF and at least an additional recording per day if they were asymptomatic. The primary outcomes of the study included change in symptomatic AF, asymptomatic AF and symptomatic non-AF episodes. The latter was defines as an episode associated with symptoms but no AF on the monitor. Secondary outcomes included change in Short Form 36 quality of life score, Zung self-assessment anxiety score (SAS) and Zung self-assessment depression score (SDS).

Results

Out of 52 enrolled patients, 49 patients (47% male) completed the study. Patients had a mean age of 61 ± 11 years and mean duration of AF was approximately five years. The majority of patients had symptomatic AF (87.7%) and was on antiarrhythmic medication (77.6%).

Yoga training significantly reduced the number of symptomatic AF episodes (3.8 ± 3 vs. 2.1 ± 2.6; p < 0.001), symptomatic non-AF episodes (2.9 ± 3.4 vs. 1.4 ± 2.0; p < 0.001), and asymptomatic AF episodes (0.12 ± 0.44 vs. 0.04 ± 0.20; p < 0.001).

At the end of the intervention phase, yoga training was associated with significantly reduced anxiety and depression scores (p < 0.001), and significantly improved the physical functioning, general health, vitality, social functioning, and mental health domains of the QoL score (p = 0.017, p < 0.001, p < 0.001, p = 0.019, and p < 0.001; respectively).

Conclusion

In patients with paroxysmal AF, yoga training may reduce symptoms, arrhythmia burden, anxiety, and depression, and improve several parameters of quality of life.

Perspective

AF imposes a substantial socioeconomic burden in Western societies, which according to estimates from the European Union and the USA is expected to increase significantly in the next 50 years.^{1, 6} Current management of AF patients is aimed at reducing symptoms and at preventing severe complications, with antithrombotic therapy and control of the ventricular rate.^{7, 8} These therapies may alleviate symptoms; however, symptom relief may require additional rhythm control therapy (i.e., antiarrhythmic drugs or catheter ablation). Both these therapies are associated with increased costs which tend to equalize at approximately five years.⁹

This proof-of-concept study by Lakkireddy et al. provides evidence that yoga may be a low-cost intervention with a complementary role in the reduction of symptomatic AF episodes or AF burden. Given that in the following years elderly patients will constitute the vast majority of AF patients,¹ the relative safety of yoga training, and several added benefits of yoga, such as the improvement in the QoL, the reduction of anxiety and depression, and the beneficial role in improving mobility and preventing falls,¹⁰ make the findings of this study all the more pertinent.

The mechanism, however, by which yoga training achieved a reduction in AF burden remains unclear. At the end of the yoga intervention period, patients had a significant reduction in heart rate, systolic and diastolic blood pressure. Blood pressure reduction by yoga is well-studied and a recent meta-analysis has demonstrated that yoga is effective in reducing both systolic and diastolic blood pressure.¹¹ Evidence suggests that one way this effect is mediated is through slow yogic breathing, which increases baroreflex sensitivity and decreases both systolic and diastolic blood pressure.¹² The drop in systolic blood pressure observed in the YOGA My Heart Study correlated with the reduction in AF episodes, suggesting a link, which could involve left ventricle afterload reduction.

Moreover, since the influence of the autonomic nervous system on triggering and perpetuation of AF is well established,¹³ the modulation of autonomic tone by yoga training may restore a balance between sympathetic and parasympathetic activity and prevent AF episodes.¹⁴ Other potential mechanisms for the reduction of AF burden, as presented by Lakkireddy et al., could include improvement in endothelial dysfunction and reduction of inflammation, which may reduce susceptibility to AF.

The findings of the YOGA My Heart Study call for further investigation in order to elucidate the involved mechanisms and fully identify the beneficial effects of yoga for patients with AF. First of all, the hypothesized yoga-induced changes in autonomic tone and in markers of systemic inflammation or endothelial function need to be confirmed in new experimental studies. Another significant question we need to address is the number of yoga sessions per week required to achieve a sustainable, long-term, antiarrhythmic effect. In this study, counter-intuitively, the greatest reduction in AF episodes was achieved by the patients with the least sessions (≤2), whereas the greatest reduction in systolic blood pressure and heart rate was achieved by the patients with the greatest number of sessions (>4).

Finally, the idea of introducing yoga training in patients with permanent AF as a complementary therapy for adequate rate control and QoL improvement is intriguing, and a new study addressing this would be equally interesting.

References

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2. Patel D, Mc Conkey ND, Sohaney R, Mc Neil A, Jedrzejczyk A, Armaganijan L. A systematic review of depression and anxiety in patients with atrial fibrillation: the mind-heart link. Cardiovasc Psychiatry Neurol 2013; 2013:159850.
3. Thrall G, Lane D, Carroll D, Lip GY. Quality of life in patients with atrial fibrillation: a systematic review. Am J Med 2006; 119:448 e1-19.
4. Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety, and depression. Part II--clinical applications and guidelines. J Altern Complement Med 2005; 11:711-7.
5. Lakkireddy D, Atkins D, Pillarisetti J, Ryschon K, Bommana S, Drisko J, et al. Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: the YOGA My Heart Study. J Am Coll Cardiol 2013; 61:1177-82.
6. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:2370-5.
7. European Heart Rhythm A, European Association for Cardio-Thoracic S, Camm AJ, Kirchhof P, Lip GY, Schotten U, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31:2369-429.
8. Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:1935-44.
9. Gorenek B, Kudaiberdieva G. Cost analysis of radiofrequency catheter ablation for atrial fibrillation. Int J Cardiol 2013. [Article In Press]
10. Tiedemann A, O'Rourke S, Sesto R, Sherrington C. A 12-Week Iyengar Yoga Program Improved Balance and Mobility in Older Community-Dwelling People: A Pilot Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2013.
11. Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for hypertension: systematic review and meta-analysis. Evid Based Complement Alternat Med 2013; 2013:649836.
12. Mason H, Vandoni M, Debarbieri G, Codrons E, Ugargol V, Bernardi L. Cardiovascular and respiratory effect of yogic slow breathing in the yoga beginner: what is the best approach? Evid Based Complement Alternat Med 2013; 2013:743504.
13. Katritsis DG. Autonomic denervation for the treatment of atrial fibrillation. Indian Pacing Electrophysiol J 2011; 11:161-6.
14. Khattab K, Khattab AA, Ortak J, Richardt G, Bonnemeier H. Iyengar yoga increases cardiac parasympathetic nervous modulation among healthy yoga practitioners. Evid Based Complement Alternat Med 2007; 4:511-7.

Keywords: Anti-Arrhythmia Agents, Anxiety, Atrial Fibrillation, Autonomic Nervous System, Baroreflex, Blood Pressure, Depression, Heart Failure, Heart Rate, Mental Health, Self-Assessment, Yoga

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