The impact of Tai Chi exercise on coronary heart disease:
A systematic review
Alona Dalusung-Angosta, PhD, APN, FNP, NP-C (Assistant Professor)1,2
1University of Nevada, Las Vegas, School of Nursing, Las Vegas, Nevada
2University of Hawaii at Manoa School of Nursing and Dental Hygiene, Honolulu, Hawaii
Tai Chi; coronary heart disease; hyperlipidemia;
Alona Dalusung-Angosta, PhD, APN, FNP, NP-C,
University of Nevada, Las Vegas School of
Nursing, 4505 Maryland Parkway, Las Vegas,
Tel: 702-895-3360 ext. 1218 (office),
702-361-2273 (clinic office);
Received: May 2009;
accepted: November 2009
Purpose: (a) To explore current studies on Tai Chi and its impact on coronary
heart disease (CHD), (b) provide critique of existing studies, and (c) provide
recommendations for clinical practice and future research.
Data sources: Comprehensive review of literature.
Conclusions: TaiChi is a safe alternative exercise for patients who are at risk of
CHD or with existing CHD. Implementing Tai Chi exercise may improve serum
lipids, blood pressure, and heart rate.
Implications for practice: Nurse practitioners (NPs) are in an ideal position
to facilitate health promotion and disease prevention. NPs may prescribe Tai
Chi as an alternative exercise therapy for their patients who are at risk for
developing CHD and even for those with existing CHD. Tai Chi exercise may
help prevent and even reverse the progression of cardiac disease.
Coronary heart disease (CHD) is the leading cause of
death in the United States (U.S.). Nearly every 25 sec-
onds, an American will have a coronary event related
to CHD, and every minute someone will die from one
(American Heart Association [AHA] Heart Disease &
Stroke Statistics, 2011 Update). The literature reflects
that many of the major risk factors of CHD are modifi-
able (Smeltzer, Bare, Hinkle, & Cheever, 2008). In fact,
the major risk factors for CHD—physical inactivity, over-
weight, hypertension (HTN), and elevated serum lipids—
remain a major issue for most Americans (AHA, Heart
Disease & Stroke Statistics, 2011 Update).
However, there are treatment approaches to combat
these problems that include both pharmacological and
nonpharmacological modalities. Although pharmacologi-
cal therapy for HTN and hyperlipidemia is often empha-
sized in clinical research (Wang, Lan, Chen, & Wong,
2002), nonpharmacological therapy and lifestyle modifi-
cations, such as physical activity, are also recognized by
The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7, 2009) as an alternative approach
for preventing CHD.
Regular physical activity in the form of exercise has
been used as an alternative therapy for many cardio-
vascular diseases, particularly CHD (Anspaugh, Hunter,
& Dignan, 1996). The National Heart, Lung, and Blood
Institute and AHA highly recommend exercise to indi-
viduals with and without CHD as a result of its im-
pact on cardiovascular health. It is well documented
that exercise prevents and even reverses CHD (Apullan
et al., 2008; Freeman, 2009), combating risk factors such
as hyperlipidemia, HTN, obesity, and type 2 diabetes mel-
litus (Booth, 2000). Exercise improves serum lipids in
patients with hyperlipidemia by lowering serum triglyc-
eride levels, total cholesterol, and low-density lipopro-
tein cholesterol (LDL-C) levels, while increasing high-
density lipoprotein cholesterol (HDL-C) levels (AHA,
Heart Disease & Stroke Statistics, 2011 Update; Anspaugh
et al., 1996; CDC, 2001; Rothenbacher, Koenig, & Bren-
ner, 2006; Tran & Weltman, 1985). Even intermit-
tent or several short exercise sessions can positively
alter serum lipids. In sedentary individuals, lipopro-
tein and lipid changes can even occur after a single
exercise session when one expends at least 350 kcal
(Altena, Michaelson, Ball, & Thomas, 2004; Crouse,
Journal of the American Academy of Nurse Practitioners 23 (2011) 376–381 C ?2011 The Author(s)
Journal compilation C ?2011 American Academy of Nurse Practitioners
Tai Chi and CHD
O’Brien, Grandjean, Lowe, & Rohack, 1997; Visich et al.,
The U.S. Department of Health and Human Services
(2008) developed a list of recommendations on health
promotion and disease prevention outlined in the Healthy
People 2010 Objectives. Reduction of cardiovascular deaths
and promotion of physical activity are two of the ma-
jor goals outlined in this document. Therefore, healthcare
providers are encouraged to promote healthy lifestyle by
counseling their patients to engage in physical activity to
reduce CHD risks.
Many individuals engage in exercise programs that are
enjoyable and interesting to them. In addition, exercises
that are low impact, do not require special equipment,
and are low in cost are more appealing to individuals re-
gardless of age, race, and gender (Maxwell, Bastani, Vida,
& Warda, 2002). One type of low-impact exercise that
has gained popularity in recent years is Tai Chi. Studies
have shown associations between Tai Chi exercise and
improved cardiovascular health. Tai Chi reduces CHD risk
by improving blood pressure (BP; Yeh, Wang, Wayne, &
Phillips, 2008) and serum lipids (Lan, Chen, Wong, &
Lai, 2008a; Lan, Su, Chen, & Lai, 2008b; Taylor-Piliae
& Froelicher, 2004; Taylor-Piliae, Haskell, & Froelicher,
2005; Taylor-Piliae, Haskell, Scotts, & Froelicher, 2006;
Thomas et al., 2005; Tsai et al., 2003; Zhang & Fu,
2008). Furthermore, Tai Chi has been shown to be as
equally effective as aerobic exercise in reducing both
systolic and diastolic BP (Young, Appel, Jee, & Miller,
Theoretical base and therapeutic uses
of Tai Chi
Tai Chi, also known as Tai Chi Chuan or Shadow Boxing,
is a mind-body practice that originated in China in ap-
proximately 12th century A.D. and is currently used as an
alternative form of physical activity practiced in the U.S.
and other parts of the world (National Center for Comple-
mentary and Alternative Medicine [NCCAM], NCAAM,
2011; Tsai et al., 2003). The underlying concept of Tai
Chi is based on the Chinese philosophy of Yin and Yang
forces. According to this concept, Yin and Yang make up
the universe. Yin is believed to have the qualities of water
(characterized by coolness, darkness, stillness, and inward
and downward directions) and to be feminine in charac-
ter (characterized by gentleness). Yang is believed to have
the qualities of fire (characterized by heat, light, action,
and upward and outward movements) and to be mascu-
line in character. Based on this philosophy, the Yin and
Yang need to be in harmony in order for the individual to
be disease free (NCCAM, 2011).
Tai Chi is well known for its slow, rhythmic move-
ments, breathing, and concentration. Lan et al. (2008a)
described Tai Chi as a low- to moderate-intensity ex-
ercise, consisting of several different movements (also
known as postures or routines), styles, and variations.
The most popular types are the long form (also known
as Yang or the classic type) and the short form (also
known as the competition style). Researchers have cen-
tered their attention on both of these forms of Tai Chi in
cardiovascular research because of their popularity in the
Problem statement and purpose
The most predictive and statistically strongest modifi-
able risk factors of CHD are hyperlipidemia, HTN, and
lack of physical activity (Freeman, 2009; Karalis, 2009).
While hyperlipidemia causes formation of plaque, which
leads to hardening of the coronary arteries (AHA, Heart
Disease & Stroke Statistics, 2011 Update; Huether & Mc-
Cance, 2004; Nakazomo et al., 1991), both hyperlipi-
demia and HTN have negative effects on the arterial
wall as they both cause atherosclerosis. If not treated,
these effects can lead to a myocardial infarction, a life-
threatening complication of CHD.
Preventing the development and progression of CHD
contributes to the overall reduction in cardiovascular
morbidity and mortality. However, little is known about
what studies have been examined and published regard-
ing Tai Chi and its impact on CHD. The purposes of this
report were to critically examine the literature to discover
the benefits of Tai Chi exercise and to evaluate what type
of Tai Chi exercise is best for improving CHD. This report
also includes a critique of the existing studies, including
their strengths and limitations.
A literature search was conducted utilizing elec-
tronic literature searches via Medline/PubMed and the
Cochrane Library database using keywords “Tai Ji,” “Tai
Chi,” “Tai Chi Chuan,” “lipids,” “hyperlipidemia,” and
“coronary heart disease.” Reference lists from related ar-
ticles were also perused. The articles were selected based
on the following criteria: (a) clinical trial studies, (b) ran-
domized control trial studies, (c) written in English, and
(d) published between the years of 1985 and 2008. When
the keyword Tai Chi was entered, there were 289 studies
found yet only 12 related to CHD. However, five of these
articles were eliminated because they did not meet the
inclusion criteria for the search.
Tai Chi and CHD
Review and results
Overview of research literature
The variables evaluated in the studies reviewed for the
purposes of this report were serum lipids, BP, and heart
rate (HR). Each study examined a combination of these
Two studies examined Tai Chi’s effect on serum lipids in
a 12-month Tai Chi exercise program (Lan et al., 2008b;
Thomas et al., 2005). Because resistance training has
been reported to improve skeletal muscle mass, memory,
and well-being (Dunn, Trivedi, & O’Neal, 2001; Fielding,
1995; George & Goldberg, 2001; Perrig-Chiello, Perrig,
Ehrsam, Staehelin, & Krings, 1998), Thomas et al. (2005)
compared the effect of resistance training and Tai Chi ex-
ercise on cardiovascular risk factors. They examined three
groups (Tai Chi, N = 64; resistance group; N = 65, con-
trol, N = 78). Lan et al. examined two groups of patients
with hyperlipidemia and HTN (Tai Chi, N = 28; control,
N = 25).
The investigators in these studies differed in their sam-
ple selection method and the type of Tai Chi that they
implemented. Lan et al. (2008b) used convenience sam-
pling and the classic Yang form of Tai Chi that consists of
108 movements. Thomas et al.’s (2005) study used ran-
dom selection of sample and utilized the short form of Tai
Chi consisting of 24 movements. These studies employed
similar exercise length (1 h, three times per week), but
they differed in overall exercise sessions. Lan et al. in-
cluded 20-min warm-up and 10-min cool-down periods
in their study, and Thomas et al. (2005) included 15-min
warm-up exercise, but no cool-down period.
In Lan et al.’s (2008a, 2008b) research, participants in
the Tai Chi group showed a significant improvement in
their serum triglyceride levels (p = .024), total choles-
terol levels (p = .025), LDL-C levels (p = .016), and an in-
crease in the HDL-C levels compared to the control group.
There were no conclusions made by the authors regard-
ing the effect of Tai Chi on serum lipid in Thomas et al.’s
(2005) study. However, their study revealed that Tai Chi
decreases serum blood glucose levels.
Two of the studies examined the effect of Tai Chi exer-
cise on lipid profile of randomly selected patients with
HTN (Tsai et al., 2003) and type 2 diabetes mellitus
(Zhang & Fu, 2008) using group comparison. These stud-
ies employed a shorter duration of a Tai Chi exercise
program (between 3 and 4 months). Both groups prac-
ticed Tai Chi three times per week and used either the
short or the long form. Tsai et al. (2003) used the classic
Yang style, and Zhang and Fu (2008) implemented the
short style. The length and sessions noted in these studies
also varied, as Tsai et al. (2003) used a 50-min exercise
session, including a 10-min warm-up and a 10-min cool-
down period. Zhang and Fu (2008) used a 70-min exer-
cise session including a 10-min warm-up without a cool-
down period. The age ranges of the participants in these
studies also varied. In Tsai et al.’s (2003) study, younger
participants, between 37 and 65 years old (mean age
was 52 years), were included in their study. Zhang and
Fu (2008) included participants who were older (57–63
The Tai Chi group in Tsai et al.’s (2003) showed an
overall improvement of their serum lipids compared to
the control group. There was a significant reduction
in the Tai Chi group’s total cholesterol (205.2–190.0
mg/dL, p ≤ .05), triglyceride levels (172.4–148.6 mg/dL,
p ≤ .05), and LDL-C levels (130–110 mg/dL, p ≤ .05).
There was also a significant increase in their HDL-C lev-
els (51.2–55.9 mg/dL, p ≤ .05) compared to the control
These findings are consistent with Zhang and Fu’s
(2008) study outcome. They also used group comparison
(Tai Chi, N = 10; control group, N = 10). Those who par-
ticipated in the Tai Chi exercise program had a reduction
in their total cholesterol, triglycerides, and LDL-C levels
and had an increase in their HDL-C levels. A significant
difference in the triglyceride levels was found in these
BP and HR
It has been documented in the literature that Tai Chi
also improves BP and HR (Yeh et al., 2008). Participants
who performed Tai Chi exercise for 3 months (Taylor-
Piliae et al., 2006; Zhang & Fu, 2008) to 12 months (Lan
et al., 2008b; Thomas et al., 2005) duration had a signifi-
cant reduction in their BP and HR. Below is an overview
and critique of the studies.
The type of Tai Chi exercise programs used by the in-
vestigators in these studies varied in styles, length, and
overall sessions. The Yang style was used in three stud-
ies (Chang et al., 2008; Lan et al., 2008b; Wang et al.,
2002) and the short form was implemented in three stud-
ies (Taylor-Piliae et al., 2006; Thomas et al., 2005; Zhang
& Fu, 2008). The length of the Tai Chi programs also var-
ied (3–12 months long) and they were implemented ei-
ther two, three, or five times per week. Two of the studies
were implemented for 3 months and TaiChi was practiced
three times per week (Taylor-Piliae et al.; Zhang & Fu,
2008). One study was completed in 9 months and Tai Chi
was practiced two times per week (Chang et al., 2008).
Two studies were completed in 12 months and Tai Chi
was practiced three times per week (Lan et al.; Thomas
Tai Chi and CHD
et al., 2005). The overall Tai Chi exercise sessions were at
least 60-min long and included warm-up and cool-down
Three studies implemented Tai Chi exercise for over 60
min without a cool-down period (Chang et al., 2008;
Thomas et al., 2005; Zhang & Fu, 2008). These studies
also differed in their sample characteristics. The major-
ity of the participants in these studies were older (> 55
years, < 75 years). Four studies used convenience sam-
pling (Chang et al., 2008; Lan et al., 2008b; Taylor-Piliae
et al., 2006; Wang et al., 2002) and three of them had
random sample selection (Thomas et al., 2005; Tsai et al.,
2003; Zhang & Fu, 2008). One study had a small sample
size (N = 53) and included participants who were tak-
ing medications and those who were on a special diet
(Lan et al., 2008b). One study had a large sample size
(N = 207), but it was conducted in China (Thomas et al.,
From this review, a picture emerges of the beneficial
effects of Tai Chi exercise on CHD. Results indicate that
practicing TaiChi improves serum lipid profiles (Lan et al.,
2008b; Thomas et al., 2005; Tsai et al., 2003; Zhang & Fu,
2008) and lowers BP and HR (Chang et al., 2008; Lan
et al., 2008a, 2008b; Taylor-Piliae et al., 2006; Thomas
et al., 2005; Wang et al., 2002; Zhang & Fu, 2008).
Some interesting findings were also noted in this re-
view. All studies differed in their sample selection. In any
research study, random selection of a sample is highly
recommended to decrease sampling error related to sys-
tematic bias (Polit, 1996). However, despite the difference
in sample selection, most studies showed similar results:
improvement in serum lipids and reduction in BP and
HR. This CHD risk improvement is promising; however,
additional studies are needed to strengthen the findings
noted in this review. All but one (Thomas et al., 2005) of
the studies reviewed used a small sample size (N ≤ 100).
Because small samples may limit the generalizability of
any study findings, further research is needed with the
inclusion of a larger population sample.
The type of Tai Chi exercise may be another factor to
consider in future research. Based on this review, the
classic Yang style did not show significant findings in BP
and HR but showed significant results in serum lipids
(Lan et al., 2008b; Tsai et al., 2003). This suggests the
Yang style may benefit individuals with hyperlipidemia
or those at risk for this disease, while the short form of
Tai Chi may benefit those with HTN and CHD.
The participants in the studies reviewed were older
(57–76 years old) except for one study (Tsai et al., 2003).
In Tsai et al.’s study, the majority of the participants were
younger (35–65 years old). It is unknown whether age
was a confounding factor influencing the overall results
of these studies. Therefore, future research is needed, in-
cluding age as a variable of interest.
Gender is another factor that may impact the outcome
of any study. Most investigators in the studies did not
mention gender in their sample selection. It is unknown
if gender was also a confounding factor that may have in-
fluenced the study results. Perhaps examination of gen-
der differences on the effect of Tai Chi on CHD is another
area that needs to be explored. One study only included
female participants (Zhang & Fu, 2008), and this limits
the generalizability of their findings.
The outcome of the studies that included participants
who were on lipid lowering and anti-hypertensive agents
(Lan et al., 2008b; Thomas et al., 2005) may not be appli-
cable to the general population. It is unknown how much
of the variability in the outcome was accounted for by the
medications. Consideration of medications as a predictor
in future research may also be an important area to ex-
Diet is another factor to consider in future research.
Only one study (Tsai et al., 2003) mentioned diet in their
research, but investigators merely stated that their partic-
ipants “maintained” dietary intake throughout the study
and did not describe what was included in the diet plan.
Therefore, it is not known what type of diet the partici-
pants had. The type of diet may have also contributed to
the study’s outcome.
Findings from this review shed important information
for future research in cardiovascular disease. This is the
first systematic review report that examined the effects of
Tai Chi specific to serum lipids. However, this review has
some limitations. Because Tai Chi is a new and emerg-
ing topic in cardiovascular research, studies focusing on
CHD are limited. In addition, this review is only Medline
based. There were no additional data available from other
Implications for practice
Nurse practitioners (NPs) are in an ideal position to
facilitate health promotion and disease prevention. NPs
may prescribe Tai Chi as an alternative exercise therapy
for their patients who are at risk for developing CHD and
even for those with existing CHD.
Short exercise sessions that are intermittent or contin-
uous, or several exercise sessions that are performed on
a single day, have been shown to alter serum lipids and
lipoprotein levels (Altena et al., 2004; Crouse et al., 1997;
Visich et al., 1996). Based on the studies reviewed, Tai Chi
exercise (either short or long form) may benefit individu-
als with hyperlipidemia and HTN. If practiced three times
Tai Chi and CHD
per week for about 60 min per session, Tai Chi may sig-
nificantly improve serum lipids, BP, and HR. NPs could
recommend this type of exercise to their patients with
borderline or Stage 1 HTN with or without hyperlipi-
demia (Lan et al., 2008b; Tsai et al., 2003).
The intensity and duration of Tai Chi exercise meets
the recommendations of major U.S. health agencies. The
American College of Sports Medicine (ACSM) and AHA
recommend that endurance exercise should be 30 min
(of moderate intensity) per day, five times per week
or 30 min (vigorous intensity) per day, three times per
week, and 8–10 strength training exercises, 8–12 repeti-
tions of each exercise two times per week (AHA, 2011;
ACSM, 2007). The U.S. Department of Health and Hu-
man Services (USDHHS, 2008) and the Centers for Dis-
ease Control (2008) recommend that exercise should
be at least 75 min a week of vigorous intensity or
150 min a week of moderate intensity and at least 2 days
of muscle-strengthening activities that involve all major
This systematic review examined the current literature
on CHD prevention, utilizing Tai Chi as primary preven-
tion. In addition, this review explored evidence to which
this nontraditional therapy positively impacts CHD. Find-
ings from this review yield significant information on the
beneficial effect of Tai Chi on CHD. Implementing Tai Chi
is a useful exercise strategy for enhancing cardiovascular
health. Knowledge obtained from this review may inspire
researchers to further explore the cardiovascular benefits
of Tai Chi. NPs are in an ideal position to reinforce health
promotion by educating their patients on the importance
of physical activity and the health benefits of routine
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