Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial

Abstract

Background: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly).

Objectives: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial.

Methods: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks.

Results: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes).

Conclusions: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).

Keywords: acute myocardial infarction; cardiac rehabilitation; coronary artery disease; rehabilitation; secondary prevention; yoga.

Graphical abstract

Figure 1

Yoga-CaRe Versus Enhanced Standard Care on Major Cardiovascular Events Cumulative incidence of major adverse cardiovascular events (composite of death, nonfatal myocardial infarction, nonfatal stroke, or emergency cardiovascular hospitalization) in the study groups. Hazard ratio for first major adverse cardiovascular event was determined using a Cox proportional hazards model and the p value used a log-rank test. Yoga-CaRe = yoga-based cardiac rehabilitation.

Central Illustration

Yoga-Based Cardiac Rehabilitation Versus Enhanced Standard Care in Acute Myocardial Infarction Cumulative incidence of major adverse cardiovascular event (composite of death, nonfatal myocardial infarction, nonfatal stroke, or emergency cardiovascular hospitalization) in the study groups. Event rates were based on Kaplan-Meier estimates in time-to-event analysis over the study follow-up period (median 21.6 months). Hazard ratio for first major adverse cardiovascular event was determined using a Cox proportional hazards model and the p value used a log-rank test. Self-rated health was assessed by the visual analogue scale of the European Quality of Life (EQ-5D-5L) questionnaire at baseline and at 12 weeks. Change score = 12 weeks minus baseline. CI = confidence interval; EQ-VAS = European Quality of Life visual analogue scale; Yoga-CaRe = yoga-based cardiac rehabilitation.

Figure 2

Hazard Ratios of Major Adverse Cardiovascular Event (Composite of Death, Nonfatal Myocardial Infarction, Nonfatal Stroke or Emergency Cardiovascular Hospitalization) for Key Subgroups of Patients Event rates were based on Kaplan-Meier estimates in time-to-event analysis over the study follow-up period (median 21.6 months). Hazard ratio for first major adverse cardiovascular event was determined using a Cox proportional hazards model and the p values were calculated by using a log-rank test. CI = confidence interval; Yoga-CaRe = yoga-based cardiac rehabilitation.