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Complementary Therapies in Medicine 57 (2021) 102643

Contents lists available at ScienceDirect

Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

Yoga for secondary prevention of coronary heart disease: A systematic

review and meta-analysis
c a b b
Jingen Li a,b , Xiang Gao , Xuezeng Hao , Dimitrios Kantas , This A. Mohamed ,

a a, **
Xiangying Zheng , Hao Xu d, *, Lijing Zhang
a
Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China
b
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, 55902, United States
c
Internal Medicine Division, Tieying Hospital of Fengtai District, Beijing, 100078, China
d
Cardiovascular Diseases Centre, Xiyuan Hospital, China Academy of Chinese Medical Sciences, National Clinical Research Centre for Chinese Medicine Cardiology,
Beijing, 100091, China

ARTICLE INFO ABSTRACT

Keywords: Objectives: Yoga has been widely practiced and has recently shown benefits in patients with coronary heart
Yoga disease (CHD), however, evidence is inconsistent.
Coronary heart diseases Methods: We conducted a systematic review and meta-analysis by searching PubMed/Medline, the Cochrane
Cardiovascular risk
Central Register of Controlled Trials (CENTRAL), EMBASE and Web of Science from inception to May 31, 2020
Systematic review
for randomised controlled trials (RCTs) comparing yoga with usual care or non-pharmacological interventions in
Meta-analysis
Randomised controlled trial patients with CHD. The primary outcomes were all-cause mortality and health related quality of life (HR-QoL).
Secondary outcomes were a composite cardiovascular outcome, exercise capacity and cardiovascular risk factors
(blood pressure, lipid profiles and body mass index).
Results: Seven RCTs with a total of 4671 participants were included. Six RCTs compared yoga with usual care
and one compared yoga with designed exercise. The mean age of the participants ranged from 51.0–60.7 years
and the majority of them were men (85.4 %). Pooled results showed that compared with usual care, yoga had no
effect on all-cause mortality (RR, 1.02; 95 % CI, 0.75–1.39), but it significantly improved HR-QoL (SMD, 0.07; 95
% CI, 0.01 - 0.14). A non-significant reduction of the composite cardiovascular outcome was observed (133 vs.
154; RR, 0.63; 95 % CI, 0.15–2.59). Serum level of triglyceride and high density lipoprotein cholesterol, blood
pressure and body mass index were also significantly improved. The study comparing yoga with control exercise
also reported significantly better effects of yoga on HR-QoL (85.75 vs. 75.24, P < 0.001). No severe adverse
events related to yoga were reported.
Conclusions: Yoga might be a promising alternative for patients with CHD as it is associated with improved quality
of life, less number of composite cardiovascular events, and improved cardiovascular risk factors.

1. Introduction estimated direct and indirect cost of heart disease was $218.7 billion from
2014 to 2015 (average annual).3 Currently, 6.7 out of 100 adult Americans
Coronary heart disease (CHD) is the leading cause of death globally, live with CHD. The high prevalence and high mortality has caused a
causing 9.4 million deaths in 2016.1 In United States, the number of substantial socioeconomic burden on countries worldwide.3
2
people with CHD increased by 74.9 % from 1990 to 2017 and the Sedentary life style, an independent risk factor for CHD, is associated

Abbreviations: BMI, body mass index; BP, blood pressure; CABG, coronary artery bypass graft; CHD, coronary heart disease; CI, confidence interval; CLSP,
conventional lifestyle program; CR, cardiac rehabilitation; HDL-C, High density lipoprotein cholesterol; HR-QoL, health-related quality of life; LDL-C, low density
lipoprotein cholesterol; MD, mean difference; PCI, percutaneous coronary intervention; RCT, randomized controlled trial; RR, risk ratio; TC, total cholesterol; TG,
triglyceride; WHO, World Health Organization; SMD, standardized mean differences; YLSP, yoga based lifestyle program.
* Corresponding author at: Cardiovascular Diseases Centre, Xiyuan Hospital, China Academy of Chinese Medical Sciences, National Clinical Research Centre for
Chinese Medicine Cardiology, XiYuan CaoChang 1, Haidian District, Beijing, 100091, China.
** Corresponding author at: 5# Haiyuncang Hutong, Dongcheng District, Beijing, 100700, China.
E-mail addresses: [email protected] (H. Xu), [email protected] (L. Zhang).

https://doi.org/10.1016/j.ctim.2020.102643
Received 21 August 2020; Received in revised form 15 November 2020; Accepted 7 December 2020
Available online 15 December 2020
0965-2299/© 2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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J. Li et al. Complementary Therapies in Medicine 57 (2021) 102643

with at least a two-fold increase in the risk for coronary events.4 Numerous events. Outcome data were abstracted at the end of intervention and for
studies have demonstrated that exercise is associated with outcomes not reported at the end of intervention but during interven tion,
5–8 Based on these find
reduced risks of coronary events and mortality available data with longest duration of intervention were abstracted.
ings, exercise-based cardiac rehabilitation (CR) programs were devel oped
for the secondary prevention of CHD. Exercise-based CR has established
itself as an effective strategy for secondary prevention for CHD,9–11 and 2.3. Search methods
has received highest possible recommendation (IA) in guidelines.
12
However, the infrastructure and multidisciplinary teams We searched the electronic database of PubMed/Medline, CENTRAL,
needed to deliver exercise-based CR are expensive and unavailable to many EMBASE, and Web of Science from inception to May 31, 2020. Refer ences
patients, especially in low- and middle-income countries. There fore, of potentially eligible studies were hand-searched. The World Health
alternative and cost-effective models of CR are needed to ensure participation Organization (WHO) International Clinical Trials Registry Plat form Search
globally. Portal (http://apps.who.int/trialsearch/) and the clinical trial registration
Yoga is gaining increasing popularity around the world and has been platform (https://clinicaltrials.gov/) were searched for potential eligible studies.
adapted for use in complementary and alternative medicine in North America No restriction on language was applied.
13
and Europe It is an ancient mind-body exercise that includes three basic Search strategies were constructed around ‘yoga’ and ‘coronary heart
components, namely ‘Asana’ (posture), ‘Pranayama’ Its principle is to disease’ for the four electronic databases (Appendix).
14
(breathing), and ‘Dhyana’ (meditation) achieve the integration and the
balance of body, mind, and spirit to boost the physical, mind, and spiritual 2.4. Data collection and analyses
health. Many studies have demonstrated that yoga could modify
cardiovascular risk factors, such as blood pres sure (BP), lipid profiles, Two authors independently screened and assessed the eligibility of
blood glucose and anxiety,15–19 but evidence of yoga for secondary retrieved studies. Data on study (e.g., date, area), participants (e.g. diagnosis,
20
prevention of CHD is limited. A Cochrane review in 2015 tried to assess age, gender), interventions (e.g. yoga type, frequency, dura tion), control
effects of yoga on CHD outcomes by searching for randomised controlled interventions (e.g. type, duration), and outcomes (e.g. assessment time
trials (RCTs) with intervention duration of at least 6 months, but retrieved no points) were extracted independently by two review authors using a pre-
eligible study. Yet in recent years, new 21 and conflicting reports have specified data extraction form. Original trial in vestigators were contacted
emerged. For example, Prabhakaran et al. conducted a large randomised for missing or insufficient data to obtain further information. Disagreements
trial involving 3959 patients with acute myocardial infarction and reported were discussed with a third author until consensus was reached.
that compared with standard care, yoga generated a non-significant reduction
of adverse cardiovascular events and significant improvement on health
related quality of life (HR-QoL) after 12-month intervention, while Tillin et al. 2.5. Assessment of risk of bias
22
found no benefit of additional yoga to usual care in patients after an acute
coro nary syndrome. Therefore, an exhaustive systematic review is needed Risk of bias was independently assessed by two authors using the
to systematically assess efficacy and safety of yoga for secondary preven Cochrane Collaboration’s tool for assessing risk of bias.24 The following
tion of CHD and to determine the possibility of yoga as an alternative and specific domains were assessed: selection bias (random sequence gen
complementary CR model. eration, allocation concealment), performance bias (blinding of partic ipants
and personnel), detection bias (blinding of outcome assessment), attrition
bias (incomplete outcome data, loss to follow-up clearly re ported and
2. Methods balanced or not), reporting bias (selective reporting, if pro tocol is not
available, reporting bias were assessed by whether the outcomes listed in
This review was registered at PROSPERO and conducted according 23 the methods section were all properly reported in the results section) and
to the PRISMA guidelines and the recommendations of the Cochrane other bias (sample calculation).
Collaboration.24
2.6. Risk of publication bias
2.1. Study eligibility criteria
We planned to assess the risk of publication bias for meta-analyses that
Studies meeting the following criteria were eligible: 1) RCTs; Quasi RCTs include at least 10 studies using funnel plots. However, only 7 studies were
and non-randomized follow-up results of RCTs were excluded; 2) participants included, and therefore, risk of publication bias was not evaluated.
with diagnosis of CHD (e.g. history of myocardial infarc tion, post-
percutaneous coronary intervention [PCI], post-coronary ar tery bypass
grafting [CABG], stable or unstable angina); 3) comparing yoga with standard 2.7. Data synthesis
care or non-pharmacological intervention. No re strictions were made
regarding yoga type, length, frequency, or dura tion. Head-to-head Statistical analyses were conducted using the RevMan software (version
comparisons of different types of yoga without a non yoga control group 5.3). Risk ratios (RRs) with 95 % confidence interval (CI) were calculated for
were excluded. Studies with co-intervention not applied simultaneously in all dichotomous data and weighted mean differences (MDs) or standardized
groups were not eligible; 4) reporting at least one of study outcomes. mean differences (SMDs) with 95 % CI for continuous data. Heterogeneity
Abstracts without full text even after con tacting the author were excluded. was explored before the performance of meta analyses for all outcomes.
Heterogeneity was detected using a stan dard chi-square test with a
significance level of P < 0.10. The I
2
statistic
2.2. Study outcomes was applied to quantify heterogeneity across studies (0–100 %; 1–49 %=
low, 50–74 %=moderate, 75–100 %=high heterogeneity). Random-ef fects
For this review, the primary outcomes were all-cause mortality and HR- model was adopted considering the potential clinical heterogeneity between
QoL. Secondary outcomes included a composite cardiovascular outcome studies.
(all-cause mortality, myocardial infarction, stroke, revascu larisation and
rehospitalisation due to cardiac cause), cardiovascular risk factors (BP, lipid 2.8. Subgroup analysis
profiles, body mass index [BMI]), and exercise capacity. The safety outcome
was number of patients reporting adverse We planned to do subgroup analyses according to the different

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population and intervention duration but were unable to do these ana lyses due The length of each yoga session varied from 30 min to 75 min and the frequency
to inadequate studies. from once to 14 sessions per week. The duration of yoga practice ranged from
14 weeks to 12 months. Control interventions in 6 of the 7 trials were standard
2.9. Sensitivity analyses or usual care.21,22,26,28 –30 And the remaining one trial 25,27 compared yoga
based lifestyle program (YLSP) with a designed conventional lifestyle program
To test the robustness of our analysis, we conducted sensitivity an alyses (CLSP) head to head with conventional post-CABG CR administered to both
on the primary and composite cardiovascular outcome by omit ting one study groups. One trial
22
at a time. also included CR in usual care for both groups. All outcome data were post-
21
intervention data, except HR-QoL in one trial which only report HR-QoL after 3-
3. Results months’ intervention rather than at the end of inter vention (12-months).

3.1. Literature search

3.3. Risk of bias
The literature search and screen process are presented in Fig. 1. A total of
460 citations were retrieved after systematic search. After removing duplications All included 7 trials did not report on the blinding of the participants and
and screening titles and abstracts, 27 full-text articles were reviewed for eligibility. personnel. However, due to the specialty of yoga intervention and study design,
Ultimately, 7 trials (8 records) with a total of 4671 patients were included it was impossible for these trials to conduct blinding and therefore all 7 trials
(excluded records were listed in the Appendix).21,22,25–30 Two articles reported were rated as high risk of performance bias (Fig. 2).
the same trial on different outcomes.25,27 Four trials 22,28–30 not reporting whether outcome assessors were blin ded to
trial allocation were assessed as unclear risk of detection bias.
Two trials 29,30 not reporting the methods of random sequence genera tion
26–30
3.2. Characteristics of included studies and participants and 5 trials not reporting methods of random sequence
concealment were rated as unclear risk of selection bias. One trial reporting 22
Of the 7 trials included, 6 21,26–30were conducted in India, and the significantly more loss to follow-up in the yoga group than the control group was
remaining one was conducted in the United Kingdom (Table 1).22 Pa tients rated as high risk of attrition bias and three trials not reporting loss to follow-up
26,29,30
enrolled were all with CHD and the mean age of the patients ranged from 51.0– were assessed as unclear risk of attrition bias. All trials were rated as
60.7 years and the majority of the patients were men (3988 [85.4 %]). No trials low risk of selective reporting bias for reporting all outcomes listed in the methods
explicitly described yoga type, and yoga intervention in all included trials section including the negative outcomes in the results section. Five trials
comprised three basic elements of yoga (physical posture, breathing exercise 22,26,27,29,30 reporting whether the process of sample calculation was not
and meditation/relaxation) conducted were rated as unclear risk of other bias (Fig. 2).
(Table 2). Yoga length, frequency and duration varied between trials.

Fig. 1. Flow-chart of study selection. CHD, coronary heart disease; RCT, randomized controlled trial.

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Table 1
Characteristics of included trials.
Study ID Region Target population Sample Mean age (I/ Male Intervention Control Duration Outcome AEs

size (I/ C) (I/C)

C)

Prabhakaran India 18ÿ 80 years, acute 1970/ 53.4 ± 11.0/ 53.4 1699/ yoga-based cardiac Enhanced standard care 12 m Death, cardiovascular events, I:
21
and in 2020 myocardial 1989 1709 rehabilitation + standard (standard HR-QoL, AEs 24
infarction within the ± 10.8 care care + educational advice) C:

past 14 days 35ÿ 26

Tillin et al United 80 years, referral 40/40 57.4 ± 3.3 28/26 Yoga + usual care Usual care (including 3m HR-QoL, BP, lipid 0
22
2019 Kingdom to CR /56.9 ± 3.1 CR) profiles, AEs, exercise
following an ACS capacity
(MI, PCI, CABG)
Yadav et al India stable CAD patients below 40/40 55.8 ± 9.0 NA Yoga + conventional medicine Conventional medicine 3m BP THAT
26
2015 65 years of age of both
sexes established
Raghuram et al India double or triple vessel 150/ 53.3 ± 6.4/ 52.6 all yoga based life style physiotherapy based life 12 m Death, HR-QoL, BMI, lipid THAT
27
2014 disease posted for 150 modification program style modification program profiles
Eraballi et elective CABG ± 6.8 (matched yoga)
25
al 2018
Pal et al 2011 India patients with 85/85 58.9 ± 9.4 72/72 Yoga + conventional medicine Conventional medicine 6m Death, BP, lipid THAT
28
coronary artery /58.6 ± 10.5 profiles
disease
Manchanda and India male patients with 21/21 51 ± 9 all Yoga + standard care Standard care 12 m revascularization, death, 0
29
al 2000 angiographically proven /52 ± 10 lipid profiles, exercise
CAD capacity, AEs
Mahajan et al 30 India Male aged 56ÿ 59 years 22/18 56ÿ 59 all Yoga + usual care Usual care 14w Lipid profiles THAT

1999 with stable angina

AEs, adverse events; ACS, acute coronary syndrome; BMI, body mass index; BP, blood pressure; C, control; CABG, coronary artery bypass grafting; CAD, coronary artery
disease; CR, cardiac rehabilitation; HR-QoL, health related quality of life; I, intervention; m, months; MI, myocardial infarction; NA, not available; PCI, percutaneous
coronary intervention; w, week.

3.4. Treatment outcomes 3.4.2. Health-related quality of life

Three trials involving 4339 participants reported the outcome of HR
3.4.1. All-cause mortality QoL. Two 21,22 of the 3 trials with 4039 participants comparing yoga with
Four trials 21,25,27–29 with a total of 4471 participants reported the usual care reported HR-QoL using the visual analogue scale of the
outcome of all-cause mortality. Three 21,28,29of the 4 trials comparing European Quality of Life questionnaire (values from 0 to 100, the higher 31
yoga with usual care reported the outcome of all-cause mortality and pooled the better). Pooled results of the two trials showed significantly better
results showed no significant difference between yoga and usual care (RR, effects of yoga than usual care (SMD, 0.07; 95 % CI, 0.01 to 0.14, P =
1.02; 95 % CI, 0.75–1.39) (Fig. 3A). The remaining one trial comparing 0.02) (Fig. 3B). The remaining one trial 25,27 comparing yoga with control
25,27
yoga with control exercise reported 2 deaths (150 par ticipants) in exercise (300 participants) assessed HR-QoL by the World Health
yoga group and one death (150 participants) in control exercise group after Organization Quality of Life Instruments (WHOQOL-BREF, higher is better)
32
12 months intervention, but did not compare the difference. and reported that compared with control exercise, yoga significantly
improved HR-QoL after 1-year intervention (85.75 ± 11.2 vs. 75.24 ± 14.9,
P < 0.001).

Table 2
Characteristics of yoga intervention of included trials.
Study ID Yoga Instructor Yoga element Session length (min/ Frequency Total

type session) (per week) session

Prabhakaran et al 21 THAT yoga Physical posture (25 min/session), breathing exercise(15 min/ session), meditation/ Session1ÿ 2 Once (session 9ÿ 13+
2020 teachers who were trained relaxation exercises (15 min/session) 30min, Session 3 ÿ 13 13) twice
in the delivery of the Yoga 74min (session 3ÿ 8)
CaRe program
Tillin et al 2019 THAT certified yoga teacher Physical posture, breathing exercise, meditation/relaxation exercises yogic 75min twice 24
22
postures,
Yadav et al 2015 THAT A yoga instructor breathing exercises THAT 7 84
26

Raghuram et al THAT Yoga therapist Physical posture, breathing exercise, meditation/relaxation exercises 30min 14 672
27
2014
Eraballi et al
25
2018
28
Pal et al 2011 THAT yoga experts and faculty Jal Neti (nasal cleansing) weekly, Physical posture (17 min/ session), meditation / 35ÿ 40 min 5 120

relaxation(10ÿ 15 min/session) breathing exercise (6ÿ 7 min/session)

Manchanda et al THAT at a yoga residential centre Physical posture, breathing exercise, meditation/relaxation exercises Meditation, THAT THAT 12
29
2000 relaxation months

Mahajan et al THAT THAT breathing exercise, and stretching posture of asanas. 60 min 7 98
30
1999

NA, not available.

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3.4.3. Composite cardiovascular outcome 3.4.5. Changes of blood pressure

The composite cardiovascular events were reported in 4 trials 21,27–29 Three trials 22,26,28 (330 participants) comparing yoga with usual care
(4518 participants). Three trials 21,28,29 compared yoga with usual care with reported the outcome of BP. Pooled results showed that compared with usual
one trial reporting21
a composite event (death, nonfatal myocar dial infarction, care, yoga reduced systolic BP by 3.46 mmHg (95 % CI, = 0%) and
2
non-fatal stroke, or emergency cardiovascular hospital ization), one trial the ÿ 4.70 to ÿ 2.23, P < 0.00001; heterogeneity P = 0.41, I
29
remaining one trial reporting revascularisation and death events, and diastolic BP by 1.59 mmHg (95 %CI, -2.83 to -0.34, P = 0.01; hetero geneity,
28 2
trials 21,28,29 comparing reporting death events. Pooled results of three P = 0.18, I = 41 %) (Fig. 4).
yoga with usual care showed the risk of com posite cardiovascular events in
yoga group was reduced by 37 %, however the reduction did not reach 3.4.6. Lipid profiles
statistical significance (133 vs. 154; RR, 0.63; 95 %CI, 0.15–2.59, P = 0.46; Five trials 22,25,27–30 with 592 participants reported the changes of lipid
heterogeneity, P = 0.11, I
2
= 54 profiles. Data from three trials 22,28,29 comparing yoga with usual care were
%) (Fig. 3C). As mentioned above, the remaining one trial 25,27 comparing included in the meta-analysis and pooled results showed that compared with
yoga with control exercise reported 2 versus 1 death in yoga group versus the usual care, yoga generated significant reduction of tri glyceride (TG) level
control group after 12 months intervention, but did not compare the difference. (SMD, -0.55; 95 %CI, -0.99, to -0.10, P = 0.02; heterogeneity, P = 0.0.02, I
2
= 70 %) and increase of high density li
poprotein cholesterol (HDL-C) level (SMD, 1.31; 95 %CI, 0.83–1.80, P = 0.02;
2
3.4.4. Exercise capacity heterogeneity, P = 0.004, I = 78 %), but had no effect on low
Two trials 22,29 comparing yoga with usual care reported the with 42 density lipoprotein cholesterol (LDL-C) (SMD, ÿ 0.41; 95 % CI, ÿ 1.13. to 0.30,
29 2
outcome of exercise capacity. One trial participants reported P = 0.26; heterogeneity, P < 0.00001, I = 88 %), or total
improved exercise duration in stress test in yoga group versus deterio rated cholesterol (TC) (SMD, ÿ 0.55; 95 % CI, ÿ 1.56 to 0.45, P = 0.28; het = 94 %)
2
exercise duration in usual care group (63.8 ± 73.7 vs.ÿ 56.67 ± 117, P = 0.0007) < 0.00001, I (Fig. 4). The remaining trial 25,27 erogeneity, P
after 12-months intervention. The other 22 trial comparing yoga with control exercise also reported that compared with control
involving 80 participants reported that compared with usual care exercise, yoga significantly reduced TG level (142.57 vs 155.28 mg/dl, P =
(including CR), the additional yoga intervention did not increase walk distance 0.03) and increased HDL-C level (40.23 vs 37.17 mg/dl, P = 0.003), but had no
in 6 min walk test (between group difference, -7; 95CI, -39 to 26, P =0.70). effect on TC (163.04 vs 167.43 mg/dl, P = 0.61) or LDL-C (96.61 vs 98.77 mg/
dl, P = 0.75).

3.4.7. BMI
Two trials 25,27,28 involving 470 participants reported the outcome of
28 BMI. One trial with 170 participants comparing yoga with usual care also
reported greater reduction of BMI in the yoga group than in the usual care
group (ÿ 1.45 vs ÿ 0.96 kg/m2 , P = 0.04). The other trial 25,27 with 300
participants and a study duration of 12 months reported that compared with
control exercise (CLSP), yoga significantly reduced BMI (23.93 vs 24.93 kg/
m2 , P = 0.001).

3.5. Adverse events

Three trials 21,22,29 reported on the outcome of adverse events. One 21

trial with 3959 patients with AMI reported 24 (1.2 %) cases with serious adverse
events (noncardiac hospitalization) occurred in yoga group versus 26 (1.3 %)
cases in the enhanced standard care group (P = 0.80), and no adverse events
occurred during the yoga practice.
The remaining 2 trials 22,29 with 122 participants reported no adverse events
occurred (Table 1).

3.6. Sensitivity analyses

Sensitivity analyses by omitting one trial each time showed similar results
on the primary and composite cardiovascular outcome (Appen dix Fig. S1),
which confirmed the robustness of our findings.

4. Discussion

In this systematic review and meta-analysis, we found that yoga significantly

improved quality of life in patients with CHD and showed a non-significant
reduction on the composite cardiovascular events. BP, BMI and TG were also
reduced while HDL-C was increased by yoga intervention. No significant effect
of yoga on mortality, LDL-C and TC were observed. Although inconsistent
effect of yoga on exercise capacity was reported, no adverse event related to
yoga was reported.

4.1. Comparison with other studies

Fig. 2. Review authors’ judgments about each risk of bias item of all included To our knowledge, this is the first meta-analysis assessing efficacy 33 in
studies. and safety of yoga for secondary prevention of CHD. Lau et al. 2012

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20
and Kwong et al. in 2014 tried to search RCTs evaluating effect of among hypertension population, yoga interventions generated SBP/DBP
yoga on clinical outcomes in patients with CHD with minimum inter reductions by 11/6 mmHg compared with those that did not. Evidence of
vention duration of 6 months but retrieved no eligible study. A sys tematic effects of yoga on mortality and cardiovascular events is limited, and
review of yoga for heart disease was done in 2013 by Cramer et al. and further prospective studies are needed.
in the 34
section of CHD, the authors only identified 4 trials
with 510 participants, of which two trials 28,35 both reporting signifi 4.2. Safety of yoga
cantly better effects of yoga on blood pressure were highly likely the
same study as they were from the same research group and same Notably, yoga intervention appears safe in patients with CHD ac
research project, had similar designs and launched at the same time. To cording to the included 3 RCTs reporting no serious adverse event related
be conservative, we only included the first and properly-reported trial in to yoga in our review. Similarly, one systematic review of RCTs assessing
34
the present study.28 Besides, Cramer et al. only did the systematic review 37
and one of observational studies 38
safety of yoga all demonstrated
without pooling the data. New studies have emerged regarding effects of that most injuries or adverse events were mild and the risks were similar
yoga for CHD in recent years. Our review included these most recent to usual care or those non-yoga exercise. Cramer et al.
studies and provided the most up-to-date evidence of yoga on clinical 39
conducted a national cross-sectional survey among yoga practitioners
outcomes and quality of life for CHD. in Germany. Results of the survey showed that only 0.6 minor injuries
Regarding cardiovascular risk factors, our findings were generally happened per 1000 h of practice while the rate for general cardiovas
consistent with previous findings. A meta-analysis assessing effects of cular fitness activities per401000
and h.
running is 2.5 injuries
41

yoga in 834 prediabetic participants from 12 RCTs and 2 non-RCTs also Likewise, a national wide survey in Australia showed that 78.7 % yoga
found that yoga significantly reduced TG level, but had no effects on TC, participants reported that they had never been injured during yoga 42
LDL-C or HDL-C.
36
Chu et al. 18 assessed effects of yoga on cardiovas
practicing, and the remaining 21.3 % reported only minor injury.
cular risk factors in patients with cardiovascular disease and metabolic Therefore, we concluded that yoga intervention might be safe for pa
syndrome in a meta-analysis, and pooled results showed that compared tients with CHD.
with non-exercise controls, yoga significantly improved BMI, systolic 16
BP, diastolic BP, LDL-C, TC, TG, and HDL-C. Wu et al. conducted a meta-
4.3. Clinical implication
analysis assessing yoga for BP in 3517 general adult population, and
found that yoga generated moderate reduction on both SBP and DBP.
Although no mortality benefits of yoga in CHD patients was observed,
After adjusting publication bias and methodological study quality, Wu et
al. found that
16 it significantly improved HR-QoL, BP, BMI, TG and HDL-C, which is also
when yoga was practiced 3 sessions per week
very important. Studies have shown that every 10 mmHg

Fig. 3. Forest plots of effect of yoga on all-cause mortality, health related quality of life, and composite cardiovascular outcome. Composite cardiovascular events
comprised all-cause mortality, myocardial infarction, stroke, revascularisation and rehospitalisation. HR-QoL, health related quality of life.

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Fig. 4. Forest plots of effect of yoga on blood pressure and lipid profiles. BMI, body mass index; DBP, diastolic blood pressure; HDL-C, high density lipoprotein
cholesterol; LDL-C, low density lipoprotein cholesterol; SBP, systolic blood pressure; TC, total cholesterol; TG, triglyceride.

43
reduction in SBP generated a 20 % reduction of cardiovascular events exercise-based CR in patients with CHD, especially for patients in low
and in our meta-analysis, we observed a mean reduction of 3.46 mmHg and middle-income countries where conventional exercise-based CR is
44 45
in SBP in yoga group. Similarly, reduction of TG has and also
BMI led to lower unavailable and too expensive.
risk of cardiovascular events in previous studies. Besides, the observed
non-significant reduction of yoga on cardiovascular events also provides 4.4. Study limitations
as a support for recommendation of yoga in patients with CHD and for
further large clinical trials. Safety and benefits considered, yoga is a Although we strictly followed the PRISMA statement, there were
promising alternative and complementary choice for several limitations in our review. First, considering the small number of

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clinical outcomes (all-cause mortality and composite cardiovascular 7 Lear SA, Hu W, Rangarajan S, et al. The effect of physical activity on mortality and
cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-
events) and risk of bias of included trials, results of our meta-analysis income countries: the PURE study. Lancet. 2017;390(10113):2643–2654. https://
should be interpreted with caution. Second, due to insufficient data, doi.org/10.1016/S0140-6736(17)31634-3.
subgroup analyses by different CHD population, yoga type or interven 8 Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a
detailed pooled analysis of the dose-response relationship. JAMA Intern Med. 2015;
tion duration was not performed. Third, inter-trial comparisons are al 175(6):959–967. https://doi.org/10.1001/jamainternmed.2015.0533.
ways fraught with problems related to differences in study design, 9 Rauch B, Davos CH, Doherty P, et al. The prognostic effect of cardiac rehabilitation in the
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of randomized and non-randomized studies - the Cardiac Rehabilitation Outcome
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