Trial Finds Tangible Results From Yoga as Cardiac Rehab

Yoga-based cardiac rehabilitation did not change cardiac outcomes for people with heart failure and reduced ejection fraction (HFrEF), though there were big boosts in exercise capacity and quality of life in an Indian randomized study.
In the Yoga-CaRe HF trial of nearly 3,500 patients, there was technically no significant difference in the risk of 15-month cardiac events (death, repeat hospitalization, or stroke) whether people underwent yoga-based cardiac rehab or were assigned enhanced standard care (21% vs 22.8%; adjusted HR 0.90, 95% CI 0.79-1.05), according to Dorairaj Prabhakaran, MD, MSc, of the Centre for Chronic Disease Control in New Delhi.
On the upside, per-protocol analyses suggested reductions in the first cardiac event among the most active yoga practitioners, namely those HFrEF patients practicing yoga 6 or 7 days a week (HR 0.72, 95% CI 0.56-0.91) or more than 255 minutes per week (HR 0.73, 95% CI 0.57-0.92), Prabhakaran told the audience at the American Heart Association (AHA) annual meeting in Chicago.
Moreover, the yoga program led to improved quality of life given “a huge difference” of 8.1 points (P<0.001) in Minnesota Living with Heart Failure Questionnaire scores at 3 months, along with better exercise capacity (improvement of 25.5 m for 6-minute walking distance [6MWD], P<0.001) and enhanced health status (improvement of 0.05 points on the European quality of life questionnaire quality-adjusted utility value, P<0.001), Prabhakaran said.
Among the other secondary findings of the trial were improved frailty and smoking cessation in the yoga arm.
All in all, Prabhakaran called the yoga program a “scalable” model for cardiac rehabilitation in India that has additional “potential to be adopted in other settings with necessary validation.”
In heart failure, exercise-based cardiac rehabilitation is established for reducing the risk of all‐cause hospital admissions and heart failure‐related hospital admissions and possibly improving quality of life. These programs are underutilized, however, as they may be time-consuming and financially costly.
Hence, there is much interest in expanding the different modalities of cardiac rehab to make it more accessible and palatable options for each patient.
The yoga arm in Yoga-CaRe HF was provided a multi-prong intervention including patient education, goal-setting for lifestyle improvement, and yoga practice. Yoga sessions were supervised by a board-certified yoga practitioner over 3 months, initially in-person then virtually, with one follow-up session every 3 months until the end of the study. Participants were expected to perform home practice daily.

“The most conservative approach to evaluating … this is that it was a neutral trial from a statistical perspective. But there does seem to be some impact of doing yoga for a high-risk population,” commented Justin Ezekowitz, MBBCh, MSc, of University of Alberta in Edmonton, Canada, during a press conference.
“What should we do with our patients who want to attend and consider other options for cardiac rehabilitation? Should we consider yoga as one of those avenues? Based on this trial, if the goals are quality of life and for better functional status, the answer should be ‘yes,'” he said.
“I think these are important patient-centered endpoints that are still meritorious,” agreed session moderator Amit Khera, MD, of UT Southwestern in Dallas. “Yoga has been practiced around the world by millions of people, so to be able to assess it in this way in a very rigorous fashion was incredibly important.”
Ezekowitz highlighted the improvement in 6MWD in particular. “For people that want to walk from their front door out to their mailbox, or front door out to the local store, a 25-meter gain for patients with HFrEF is a substantial gain,” he said, on par with expectations for “medications in pulmonary hypertension, for example, so this is an important marker.”
Yoga-CaRe HF was an open-label randomized trial conducted at 16 tertiary care hospitals in India. Participants were adult patients with HFrEF, with New York Heart Association (NYHA) class II or III symptoms, who were recruited in hospital and outpatient settings.
Participants were randomized to yoga rehab (n=1,737) or enhanced standard care (n=1,755). In contrast to the yoga intervention, the controls got standard care consisting of an educational booklet and guideline-directed medical therapy (GDMT).
The cohort had a mean age of 57, with women accounting for 27% of the group. Roughly half were in NYHA functional class III, and the heart failure was of an ischemic etiology in 65% of cases. Medications at baseline largely included beta-blockers (approximately 84%), renin-angiotensin-aldosterone system inhibitors (77%), mineralocorticoid receptor antagonists (70%), and SGLT-2 inhibitors (60%). Patients were on quadruple GDMT in 38%, and triple GDMT in about 50%, at baseline.
Over the 15-month follow-up, individual clinical endpoints (e.g., all-cause death, repeat hospitalization, cardiac death, heart failure hospitalization) tended to numerically favor the yoga intervention group without reaching statistical significance.
Patient improvement in 6MWD and health status persisted to 24 months.
Additionally, Prabhakaran reported that the yoga intervention was safe, with no adverse events logged during yoga practice. Composite safety events, including all deaths and emergency/unplanned hospitalizations, reached 25.6% in the Yoga-CaRe group and 29.6% in the enhanced standard care group.
As for the caregivers involved in the trial, their own quality of life and depression were ostensibly improved with the yoga intervention.