8th Journal Reading

Effects of Yoga in Patients with Paroxysmal Monday, November 13, 2017

Atrial Fibrillation –
A Randomized Controlled Study

Maria Wahlstrom1,3, Monica Rydell Karlsson1,3, Jörgen Medin2,3 and Viveka

Frykman1,2
• Atrial fibrillation is the most common heart rhythm disturbance
associated with high mortality, morbidity and hospitalisation

• Episodes of paroxysmal atrial fibrillation (PAF)  cause

symptoms such as anxiety, stress and worry

• Patients with PAF experience deterioration in health related

quality of life (QoL) compared to the general population and
patients with other cardiovascular diseases

• To handle the emotional consequences that comes with atrial

fibrillation the patients need practical tools

• The standard treatment for PAF : medication, cardioversion

and ablation  to prevent severe complications (such as
stroke)
Yoga practice consists of
• Breathing techniques (pranayama)
• Meditation (dhyana)
• Various physical exercises (asanas)

• Yoga is known to affect both the parasympathetic and

sympathetic nervous systems

• Practising yoga can improve QoL

• Positive impact in reducing heart rate and decreasing blood
pressure
• useful in ameliorating various medical conditions

• The effect of yoga however is under debate because many

studies are small and not randomized
 Inclusion Criteria
 A diagnosis of PAF
necessitating
pharmacological treatment
 had either early or new
diagnosis of PAF and should
have been on medical
treatment for PAF for at
least three months
Exclusion Criteria
Patients with :
 difficulties understanding
the Swedish language
 Multiple concurrent medical
conditions (i.e. cancer, heart
failure and renal failure with
symptoms)
 cognitive dysfunction were
considered to have too many
difficulties to perform yoga
in a group session
• Eighty–eight patients with PAF were consecutive identified from
medical records at the arrhythmia department’s out-patient clinic and
asked by telephone to participate
• 80 patients fulfilled the inclusion criteria  randomized
 40 patients  yoga group
 40 patients  control group
• All patients met the same research-nurse twice – first at baseline and
finally after 12 weeks (within a two-week visit window after
intervention) at the end of the study  to assess QoL and
hemodynamic parameters
• Both visits (at baseline and at end of study)  held in the morning in
the same room at the hospital for both groups
• There was no change in environment for both groups’ visits
• Medication treatments were collected from medical records at
baseline and at the end of the study
 Interventions
Yoga Group Control Group
• Received standard treatment including medication, • Received standard treatment including
cardio version and catheter ablation medication, cardio version and catheter ablation

• Performed yoga in group sessions once a week • Instructed not to perform any yoga during the
during the 12-week intervention period intervention period

• Each yoga session took place in the hospital

(physiotherapy clinic), lasted one hour

• Group session had a maximum of 10 participants in

each, who were also encouraged to practice yoga
at home

• To assist with self-instructed yoga, participants

received a written program that included
descriptions of movements together with a CD
 Interventions
YOGA GROUP

• Used a yoga form called Mediyoga (http://mediyoga.com)  a

therapeutic form of yoga evolved from Kundalini yoga
• A calm, meditative yoga based on deep breathing  designed so that
participants (if needed) may sit on a chair and exercise certain
movements
 Interventions
YOGA GROUP

• The yoga program was specifically designed for people with cardiac diseases
it includes
 Movements that stretch the muscles in the chest, which facilitates deep breathing
and relaxes the body
 Each session started with deep breathing for 5–10 min followed by three
movements (back flex, back roll and Sat Kriya) that included two breathing
techniques, subsequent meditation (10 min) and relaxation (10 min)
 The intervention was performed under the instruction of an experienced yoga
instructor
 The instructor was not aware of changes in the standard medical therapy
 MEDIYOGA
1. Long, deep breaths

• Sit comfortably with support for your back, or lie stretched

out on your back. Put one hand on your stomach and your
other hand at the top of your chest. Close your eyes and
take long, deep breaths in and out through your nose.
When you breathe in, push your tummy and chest out.
Tummy first, then chest. When your lungs are fully inflated,
gently let go and breathe out through again your nose.
When you breathe out, relax your chest and stomach back
in again. When you have expelled all the air in your lungs,
wait a few seconds before breathing in again. Let your
body decide, without creating discomfort, when it is time to
take a new deep breath in again. When you can clearly
feel your stomach and chest moving in harmony with your
breathing, place your hands on your knees or arms down
by your side and let them rest there during the exercise.

• Think SAT (saaat) when breathing in and NAM (naaaamm)

when breathing out. This simple mantra means “I am true”.
Find a routine that enables you to do this several times
every day, e.g. before breakfast, lunch and dinner.
 MEDIYOGA
2. Breathing through your left nostril

• Breathe in as above with your stomach and chest,

but this time close your right nostril with your
thumb or index finger and take long deep breaths
in and out through your left nostril. Two-three
times a day.
• Think SAT on breathing in and NAM on breathing
out. This is a good breathing technique to try if you
have high blood pressure.
 MEDIYOGA

3. Spinal flex
• Sit with your back straight, towards the front of the chair so you
are away from any back support. Hold your hands steady on
your knees. Start by pressing forward the curve of your back and
pushing your chest up towards the ceiling, without letting your
head fall backwards. Try to lift your behind slightly out of the
chair. Then relax your chest downward and pull it back in on
itself, so your chest hunches back and your spine is banana
shaped – without letting your chin drop to your chest. Gently
flex forwards and back like this for 3-5 minutes. Breathe in as
you flex forwards, breathe out as you flex backwards. Calm
movements in both directions as best as you can. This should
not cause any pain in your back. Think SAT NAM in tune with
your breathing and movements.
 MEDIYOGA

4. Sat Kriya
• Sit on your heels with the arms overhead, elbows straight, arms
hugging the sides of the head, and palms together. Interlace the
fingers except for the index fingers which point straight up. Men
cross the right thumb over the left, women cross the left thumb
over the right

• Rhythmically chant aloud ‘Sat Nam,’ pulling the navel point in as

you chant ‘Sat’ and relaxing it as you chant ‘Nam.’ Try to keep the
spine still and avoid shrugging the shoulders – let the motion come
from the navel area alone. Aim to keep your rhythm and tone
consistent
 MEDIYOGA

5. Back Roll
 MEDIYOGA
5. Meditation for the heart
• 10 minutes.
• Sit comfortably with your back straight. Sit in a way that
enables you to be fully relaxed. Place the palm of your left
hand in the middle of your chest, at heart height. Put your right
hand on top of your left hand. Close your eyes and sit like this,
ideally with some soothing and tranquil instrumental music in
the background, holding your heart in your hands. Think to
yourself that you are allowing yourself to feel good in your
heart, to become whole again. Allow out all the feelings that
come to you and keep coming back to the thought that you are
allowing yourself to become whole again. Sit like this for at
least 10 minutes
 Quality of Life Questionnaire :
Primary • Short- Form Health Survey (SF-36), dimensions:
physical health and mental health
• VAS-scale from EuroQoL-5D (EQ-5D)

• Blood Pressure and Heart Rate

Secondary With a calibrated automated blood pressure meter
(OMRON)
This study results show that yoga significantly improves QoL and that their increased comfort allows
them to more easily tolerate their conditions

Decreasing blood pressure and resting heart rate may give patients a feeling of security

One of the most important treatment goals in atrial fibrillation is to reduce symptoms and improve
QoL

The result of our study is that a 12-week yoga program can improve QoL in patients with PAF
The two groups were not completely balanced; the yoga group estimated a lower QoL
regarding EQ5D VAS-scale and SF-36 mental health at baseline

This study had relatively more women and patients with a previous stroke/transitory
ischaemic attack (TIA) in the yoga group

Earlier studies  women with PAF estimate poorer QoL than men and patients who
have suffered a stroke estimate poorer QoL than the general population

This asymmetry could influence results

Factors that can contribute to QoL may occur at different times, which can affect QoL measurements

The measurements were equal for both groups in this study and therefore should have no influence
on the results

In this study heart rate as well as systolic and diastolic blood pressure was significantly lower in the
yoga group compared to the control group

Literature recommends slow deep breathing to lower blood pressure, and this study used a yoga form
based on slow deep breathing

One important reason for this is that yoga may give patients with PAF a method to gain some self-
control over their symptoms
• This study included a rather small number of included
subjects
• The differences between the study groups at baseline
• This study also included patients with PAF irrespective of
their symptoms. The effect may be more pronounced if
the study only includes patients with a symptomatic
arrhythmia
• The numbers of episodes of atrial fibrillation and
symptoms were not reported in this study
• The group therapy of yoga can have a placebo effect and increase QoL

• SF-36 and EQ-5D VAS-scale are general quality of life questionnaires and
include no questions about symptoms  A more specific form to
evaluate QoL for patients with PAF would be more appropriate
• Yoga with light movements and deep breathing may lead to
improved QoL, lower blood pressure and decreased heart rate in
patients with PAF compared to a control group not performing yoga
• Yoga could be a complementary treatment method to standard
therapy.
13.7 %
SECTION 2: OVERALL ASSESSMENT OF THE STUDY

How well was the study done to minimise High quality (++)
bias?
Acceptable (+)
Code as follows:
Low quality 
Unacceptable (-)– reject 0 

Taking into account clinical considerations, your yes, for the within group
evaluation of the methodology used, and the
statistical power of the study, are you certain
that the overall effect is due to the study
intervention?
Are the results of this study directly applicable yes,but it still needs further research with the
to the patient group targeted by this guideline? similar baseline characteristic of the subjects,
bigger sample size, number of arrhythmia
symptoms episodes
 ATRIAL FIBRILASI (AFib)

• Aktivasi atrium yang

tidak terkoordinasi,
suatu aritmia yang
ditandai oleh gangguan
koordinasi dari
depolarisasi atrium
Normal

A Fib
A Fib
 A Fib
Secara klinis, terdapat 5 tipe AF yang dapat dibedakan berdasarkan presentasi dan
durasi aritmia.
• First diagnosed AF: setiap pasien yang baru pertama kali terdiagnosis dengan AF
tanpa melihat durasi atau beratnya gejala yang ditimbulkan oleh AF tersebut
• Paroxysmal AF: AF yang biasanya hilang dengan sendirinya dalam 48 jam sampai 7
hari. Jika dalam 48 jam belum berubah ke irama sinus maka hanya kemungkinan
kecil untuk dapat berubah ke irama sinus lagi sehingga perlu dipertimbangkan
pemberian antikoagulan.
• Persistent AF: episode AF yang bertahan sampai lebih dari 7 hari dan membutuhkan
kardioversi untuk terminasi dengan obat atau dengan elektrik.
• Long standing persistent AF: episode AF yang berlangsung lebih dari 1 tahun dan
strategi yang diterapkan adalah kontrol irama jantung (rhythm control).
• Permanent AF: jika AF menetap dan secara klinis dapat diterima oleh pasien dan
dokter sehingga strategi managemen adalah tata laksana kontrol laju jantung (rate
control)
 Yoga for A Fib
• Although the precise mechanisms underlying the benefits in AF remain
unclear
• Yoga can decrease systemic stress  down regulate the
hypothalamic-pituitary-adrenal axis  reduce sympathetic nervous
system activity + increase parasympathetic activity
• improve endothelial function and reduce inflammation  improve
blood vessel + preventing or minimizing atrial remodeling 
decreasing the progression of the arrhythmia
 Yoga for A Fib

• Study has hypothesized how pranayamic breathing interacts with the nervous system
affecting metabolism and autonomic functions

• During inspiration, stretching of lung tissue produces inhibitory signals by action of slowly
adapting stretch receptors (SARs) and hyperpolarization current by action of fibroblasts

• SARs are the lung vagal afferents responsible for eliciting the reflexes evoked by
moderate lung inflation

• SARs play a role in Both the inhibitory impulses and hyperpolarization current 
synchronize neural elements leading to the modulation of the nervous system + the
parasympathetic state  controlling breathing pattern, airway smooth muscle tone,
systemic vascular resistance and heart rate  decreased heart rate + lowering blood
pressure
Sistim Aksis Hypothalamic-Pituitary-Adrenal axis HPA
 EQ-5D VAS Scale
• EQ-5D was first introduced in 1990 by the EuroQol
Group
• This group was initially formed in 1987 with the
researchers of multidisciplinary areas from five
European countries; Netherlands, UK, Sweden, Finland,
and Norway
• Instrument which is not specific to disease but
standardized and can be used as a complement for
existing health-related quality of life (HRQoL) measures
• Capable of being sent as a postal questionnaire for
self-completion, easy to complete, applicable to
everyone
• Visual analogue asking to mark health status on the
day of the interview on a 20 cm vertical scale with end
points of 0 and 100
 SF 36
• The Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36
Health Survey) is a measure of health status designed for use in clinical
practice, research, health policy evaluations, and general population
surveys. (McHorney et al. 1994)

It includes eight scales that assess the following general health concepts:
• Physical functioning
• Role limitations due to physical health problems
• Bodily pain
• General health perceptions
• Vitality
• Social functioning
• Role limitations due to emotional problems
• Mental health
SF 36
 Kundalini Yoga
• cheetana merupakan bagian dari Energi Tuhan YME yang diperlukan
untuk berfungsinya manusia
• chetanaa aktif – Juga dikenal sebagai prana-shakti atau energi vital.
Energi vital atau prana-shakti tersebut memelihara dan memberikan
energi kepada tubuh fisik, pikiran, Intelektual dan ego.
• chetanaa non–aktif – Yang dikenal sebagai Kunḍalinī. Kundalini ini
tertidur dalam diri seseorang sampai dibangkitkan

• Kundalini Yoga adalah latihan yang bertujuan untuk membangkitkan

Kundalini
 A Typical Kundalini Yoga Session

1. Opening Mantra
2. Warm-Up Exercises
3. Main Kriya
(Specific Set of
Exercises)
4. Meditation
5. Deep relaxation
6. Closing Mantra
 Catheter ablation
• a procedure that uses radiofrequency energy (similar to microwave
heat) to destroy a small area of heart tissue that is causing rapid and
irregular heartbeats.
• Destroying this tissue helps restore heart’s regular rhythm.
• The procedure is also called radiofrequency ablation.
 ANCOVA
• Use of ANCOVA is to adjust for preexisting differences in nonequivalent
(intact) groups. This controversial application aims at correcting for
initial group differences (prior to group assignment) that exists on
Dependent Variable among several intact groups. In this situation,
participants cannot be made equal through random assignment, so
Covariate Variables are used to adjust scores and make participants
more similar than without the Covariate V. However, even with the use
of covariates, there are no statistical techniques that can equate
unequal groups