INTERNATIONAL JOURNAL OF YOGA THERAPY – No. 21 (2011) 73
Acknowledgments: e authors thank ACYTER yoga instructor Selvi L. Vithiyalakshmi for her assistance during the
study. We also thank the directors of MDNIY and JIPMER for their support. is study was possible only because
ACYTER has been established as a collaborative venture between the Morarji Desai National Institute of Yoga, New
Delhi, and JIPMER, Puducherry, with funding from the Department of AYUSH in the Ministry of Health and Family
Welfare, Government of India.
Immediate Effect of Sukha Pranayama on
Cardiovascular Variables in Patients of Hypertension
Ananda Balayogi Bhavanani, MBBS, ADY, Zeena Sanjay, BNYS,
Madanmohan MD, MSc
The Advanced Centre for Yoga Therapy, Education and Research, Jawaharlal Institute of Postgraduate Medical
Education & Research, Puducherry, India
Abstract: Hypertension is one of the most common health disorders, and yoga has been shown to be an eﬀective
adjunct therapy in its management. Earlier studies have reported blood pressure (BP)-lowering eﬀects of slow,
deep breathing after 3 weeks and 3 months of training and beneﬁcial immediate eﬀects of slow, deep breathing
in reducing premature ventricular complexes and lowering blood pressure. None of these immediate studies used
the concept of pranayama, involving conscious internal awareness of the whole breathing process. is study
was undertaken to determine the immediate cardiovascular eﬀects of sukha pranayama in hypertensive patients.
Methods: Twenty-three hypertensive patients attending the Yoga OPD at JIPMER were recruited for the study
and instructed to perform sukha pranayama for 5 minutes at the rate of 6 breaths/min. is pranayama involves
conscious, slow and deep breathing with equal duration for inhalation and exhalation. Heart rate (HR) and BP
were recorded before and immediately after the intervention. Results: Post-intervention statistical analysis revealed
a signiﬁcant (p < .05) reduction in HR and a highly signiﬁcant (p < .001) reduction in systolic pressure, pulse
pressure, mean arterial pressure, rate-pressure product, and double product with an insigniﬁcant fall in diastolic
pressure. Discussion: It is concluded that sukha pranayama at the rate of 6 breaths/minute can reduce HR and BP
in hypertensive patients within 5 minutes of practice. is may be due to a normalization of autonomic cardio-
vascular rhythms as a result of increased vagal modulation and/or decreased sympathetic activity and improved
baroreﬂex sensitivity. Further studies are required to understand possible mechanisms underlying this beneﬁcial
immediate eﬀect and to determine how long such a beneﬁcial eﬀect persists.
Key words: hypertension, pranayama, yoga, breathing, blood pressure, cardiovascular disease, vagal tone
Correspondence: Ananda Balayogi Bhavanani at 25, 2nd Cross, Iyyanar Nagar, Pondicherry, India 605013.
74 INTERNATIONAL JOURNAL OF YOGA THERAPY – No. 21 (2011)
One of the most common health disorders today is hy-
pertension, or high blood pressure (BP). is health chal-
lenge aﬀects millions of people all over the world and is a
major risk factor for stroke, coronary artery disease, and
organ failure. Lifestyle modiﬁcations are universally accept-
ed not only as the ﬁrst step in the management of hyperten-
sion but also as a way to prevent hypertension.1 Lifestyle
modiﬁcations may eliminate the need for drug therapy in
borderline hypertension and decrease the dosage and/or
reduce the number of drugs need in established hyperten-
sion. It may also decrease the risk of cardiovascular diseases
directly and indirectly.
Yoga has been found to be an eﬀective adjunct therapy
for hypertension. Yoga is a true lifestyle intervention that
may include practices such as asana (postures), pranayama
(breathing), meditation, relaxation, dietary changes, and
other techniques that have been shown to aid in reducing
cardiovascular risk and high blood pressure.2 Breathing
techniques are increasingly being used for therapeutic pur-
poses, and research suggests that pranayama may be espe-
cially helpful in managing hypertension.
For example, a recent study by Pramanik and colleagues
has reported reduction in heart rate and blood pressure
following 5 minutes of slow-paced bhastrika pranayama.3
Earlier studies from our laboratory have shown the heart
rate- and blood pressure-lowering eﬀects of practicing slow,
deep breathing on a regular basis for 3 weeks and 3 months.4, 5
Deep breathing has also been reported to reduce premature
ventricular complexes.6 Joseph and colleagues demonstrated
a decrease in blood pressure after 3 minutes of slow breath-
ing at the rate of 6 breaths/min, while Kaushika and col-
leagues demonstrated that even a single 10-minute session
of slow breathing could produce a temporary fall in blood
pressure.7,8 Grossman and colleagues reported a clinically
signiﬁcant reduction in blood pressure after 8 weeks of slow
deep breathing for 10 minutes a day using a Breathe with
Interactive Music (BIM) apparatus.9
However, none of these studies on timed deep
breathing have used the yogic concept of pranayama as a
conscious internal awareness of the whole breathing pro-
cess. Further, most research on the immediate eﬀects of
pranayama has used a nonclinical, healthy sample, while
research on the therapeutic beneﬁts of pranayama has fo-
cused on long-term beneﬁts from regular practice. is
study was undertaken to determine the immediate ef-
fects of 5 minutes of a classic pranayama technique, sukha
pranayama, on cardiovascular parameters in hypertensive
patients attending the Yoga Out Patient Department at
JIPMER, Puducherry, India.
is study was conducted at the Advanced Centre
for Yoga erapy Education and Research (ACYTER).
ACYTER is a collaborative venture between Morarji Desai
National Institute of Yoga in New Delhi and the Jawaharlal
Institute of Postgraduate Medical Education & Research
in Puducherry, with funding from the Department of
Ayurveda, Yoga & Naturopathy, Unani, Siddha and
Homeopathy (AYUSH) in the Ministry of Health and
Family Welfare, Government of India. Ethical approval
was obtained by ACYTER from the Institutional Ethics
Committee for studies on the eﬀect of yoga therapy on hy-
pertension and diabetes. e present study was conducted
as a pilot study as part of this larger study on the eﬀects of
yoga therapy in patients with hypertension.
Twenty-three patients (11 men) with essential hyper-
tension attending the Yoga Out Patient Department (OPD)
run by ACYTER were selected for this study by nonran-
dom sampling. e Yoga OPD is a facility of ACYTER
where patients are referred from various departments of the
hospital to be given yoga consultation. Individualized and
group-based yoga therapy schedules are determined based
on their condition. ese schedules are then completed at
the ACYTER Yoga Hall. Regular follow-up is done on a
periodic basis at the Yoga OPD, and required changes made
in the schedule as appropriate. Participant age ranged from
45 to 70 (M = 55.13 , SEM = 1.54) years. All of the partici-
pants had experienced hypertension for more than 5 years
and were under regular medical management with one or
more antihypertensive medications at the Medicine OPD
in JIPMER. Patients of secondary hypertension and those
with history, signs and symptoms, or laboratory reports
suggestive of nephrologic, neurologic, and ophthalmologic
complications were excluded from the study. None of the
participants had any previous experience of yoga training
before attending the Yoga OPD. Informed consent was ob-
tained by one of the investigators.
Participants were taught to perform sukha pranayama in
an individual manner by a qualiﬁed yoga teacher working as
a yoga instructor in ACYTER. Sukha pranayama is a simple
type of yogic breathing that is done by consciously regulating
75PRANAYAMA AND HYPERTENSION
the inhalation and exhalation to an equal ratio, with internal
awareness of the complete breathing process involving all
sections of the lungs.10 is pranayama can be done at the
rate of 6 breaths/min by using a timed count of 5 for inhal-
ing and exhaling. e study was done in the third session of
attendance at ACYTER, after the practice had been taught
in the ﬁrst two sessions. In these preliminary sessions, partici-
pants were also introduced to simple breath–body coordina-
tion and loosening practices, along with savasana relaxation.
An overview of the practice was given to the patients,
and then they were instructed to sit upright, resting their
palms on their thighs. ey were asked to keep their eyes
closed to facilitate the development of an internal aware-
ness. e pranayama was done through both nostrils in a
calm and regular manner with a conscious eﬀort to use the
lower, middle, and upper parts of the lungs in a sequential
manner for both inhalation and exhalation. Participants
were instructed to breathe in and out for an equal count of
5 that was given by the instructor using a stopwatch. e
instructor called out counts at the rate of 6 breaths/min for
the entire duration of 5 minutes.
Heart rate (HR) and blood pressure (BP) were mea-
sured using a noninvasive semi-automatic blood pressure
monitor. Baseline measurements of HR and BP were taken
after 5 minutes of rest in a seated posture. HR and BP were
measured again after the 5 minutes of sukha pranayama.
Pulse pressure (PP) was calculated as SP-DP, mean arte-
rial pressure (MAP) as DP + 1/3 PP, rate-pressure product
(RPP) as HR × SP/100, and double product (Do P) as HR
× MAP/100. Statistical analysis was done using a student’s t-
test for paired samples. P values less than .05 were accepted
as indicating signiﬁcant diﬀerences between the baseline
and post-pranayama means.
All values are given as mean ± SEM. Immediately fol-
lowing 5 minutes of deep breathing, there was a statistically
signiﬁcant (p < .05) fall in HR from 79.3 ±2.86 to 76.57
±2.69 beats /min. e SP fell from 136.13 ± 3.32 to 126.96
± 2.54 mm Hg (p < 0.001), MAP from 97.26 ± 1.78 to
92.81±1.49 mm Hg (p < .001), RPP from 108.50 ± 5.25 to
97.82 ±4.58 units (p < .001), and Do P from 77.34 ± 3.31
to 71.34 ± 3.04 units (p < .001). PP showed a signiﬁcant fall
from 58.3 ± 2.95 to 51.22 ± 2.22 mm Hg (p < .01), while
there was a statistically insigniﬁcant fall in DP from 77.83
±1.48 to 75.74 ±1.32.
According to the Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure, normal systolic pressure
(SP) and diastolic pressure (DP) are expected to be less than
120 mm Hg and 80 mm Hg, respectively. SP between 120–
139 mm Hg and DP between 80–89 mm Hg is labelled as
prehypertension, while SP values above 140 mm Hg and
DP above 90 mm Hg are considered stage I hypertension.
SP more than 160 mm Hg and DP more than 100 mm Hg
is considered stage II hypertension (JNC VII).11
In the present study, the practice of sukha pranayama for
5 minutes at a rate of 6 breaths/min was found to reduce the
heart rate and blood pressure in patients with hypertension.
Although both systolic and diastolic pressure dropped, only
the reduction in systolic pressure was signiﬁcant. is may
be because systolic values were initially already higher than
is considered healthy. On the other hand, diastolic pres-
sure was already within the normal range. Because sukha
pranayama aims to produce a balanced state, further drops
would not be expected. e cardiovascular eﬀects were more
pronounced with regard to the MAP, RPP, and Do P. RPP
and Do P are especially signiﬁcant because they are indi-
cators of myocardial oxygen consumption and load on the
heart.12 e decrease observed following sukha pranayama
implies a lowering of strain on the heart itself. e observed
changes may in part be due to an increase in parasympa-
thetic activity and decrease in sympathetic activity, which
has been previously reported in a study of pranayama’s ef-
fects on ventricular performance.13
e beneﬁcial cardiovascular eﬀects seen in this study
may also be due to the rate of breathing. Studies by Prakash
and colleagues and Ravindra and colleagues have shown the
therapeutic beneﬁts of deep breathing at the rate of 6 breaths/
min on reducing premature ventricular complexes.6,14 e
authors suggested that this was possibly due to the increased
vagal modulation of sinoatrial (SA) and atrioventricular (AV)
nodes. e increase in vagal modulation may be responsible
for the reduction in heart rate and blood pressure seen in
this study. It has been previously suggested that breathing
at 6 breaths/min has the eﬀect of entraining all RR interval
ﬂuctuations, thereby causing them to merge at the rate of res-
piration and to increase greatly in amplitude. is increase in
RR interval ﬂuctuations enhances baroreﬂex eﬃciency and
may have contributed toward lowering blood pressure.7
e slow, deep, conscious breathing done in sukha
pranayama may also help normalize autonomic cardiovas-
76 INTERNATIONAL JOURNAL OF YOGA THERAPY – No. 21 (2011)
cular rhythms that were described by Mayer more than a
century ago.15 ese rhythms occur as a 10-second cycle in
blood pressure that is related to both vagal and sympathetic
activity. Luciano Bernardi and colleagues have shown ben-
eﬁcial eﬀects of rosary prayer and yoga mantras in restoring
these autonomic cardiovascular rhythms.16 ey reported
an increase in baroreﬂex sensitivity following such chanting
and concluded that rhythm formulas that involve breathing
at six breaths/min induce favorable psychological and pos-
sibly physiological eﬀects. A previous study by Joseph and
colleagues reported a normalization of baroreﬂex sensitivity
in hypertensive patients following just 2 minutes of breath-
ing at the rate of 6 breaths/min.7
We conclude that sukha pranayama when performed
at the rate of 6 breaths/min is eﬀective in reducing heart
rate and blood pressure in hypertensive patients after just
5 minutes of practice. is ﬁnding has potential therapeu-
tic applications in day-to-day as well as clinical situations
where blood pressure needs to be brought down quickly.
It is simple, cost-eﬀective, and may be added to the man-
agement protocol for hypertensive patients in addition to
the regular medical management of such situations. Further
studies are required to enable a deeper understanding of the
mechanisms involved. We plan to further investigate how
long the cardiovascular eﬀects persist, as this will provide
more information about its usefulness in the long-term
management of hypertension.
Sharma R, Gupta N, Bijlani RL. Eﬀect of yoga based lifestyle 1.
intervention on subjective well-being. Indian Journal of Physiology and
Vijayalakshmi P, Madanmohan, Bhavanani AB, Patil A, Babu K. 2.
Modulation of stress induced by isometric handgrip test in hypertensive
patients following yogic relaxation training. Indian Journal of Physiology
and Pharmacology. 2004;48(1):59-64.
Pramanik T, Sharma HO, Mishra S, Mishra A, Prajapati R, Singh 3.
S. Immediate eﬀect of slow pace bhastrika pranayama on blood pressure
and heart rate. Journal of Alternative and Complementary Medicine.
Madanmohan, Udupa K, Bhavanani AB, Vijayalakshmi P, 4.
Surendiran A. Eﬀect of slow and fast pranayams on reaction time
and cardiorespiratory variables. Indian Journal of Physiology and
Pal GK, Velkumari S, Madanmohan. Eﬀect of short-term practice 5.
of breathing exercieses on automonic funtions in normal human volun-
teers. Indian Journal of Medical Research. 2004;120:115-121.
Prakash ES, Ravindra PN, Madanmohan, Anilkumar R, 6.
Balachander J. Eﬀect of deep breathing at six breaths per minute on the
frequency of premature ventricular complexes. International Journal of
Cardiology. 2006; 111(3):450-2.
Joseph CN, Porta C, Casucci G, Casiraghi N, Maﬀeis M, Rossi 7.
M, Bernardi L. Slow breathing improves arterial baroreﬂex sensitivity
and decreases blood pressure in essential hypertension. Hypertension.
Kaushika RM, Kaushika R, Mahajana SK, Rajesh V. Eﬀects 8.
of mental relaxation and slow breathing in essential hypertension.
Complementary erapies in Medicine. 2006;4(2):120-6.
Grossman E, Grossman A, Schein MH, Zimlichman R, Gavish B. 9.
Breathing-control lowers blood pressure. Journal of Human Hypertension.
Gitananda Giri Swami. 10. Sukha Pranayama: pleasant or easy breath. In
Correction of Breathing Diﬃculties by Rishiculture Ashtanga Yoga. 2nd
Ed. Pudicherry: Satya Press; 2006, 84-85.
Seventh Report of the Joint National Committee on Prevention, 11.
Detection, Evaluation, and Treatment of High Blood Pressure. US
Department of Health and Human Services. NIH Publication No.
Madanmohan, Udupa K, Bhavanani AB, Shatapathy CC, Sahai 12.
A. Modulation of cardiovascular response to exercise by yoga training.
Indian Journal of Physiology and Pharmacology. 2004;48(4):461-65.
Udupa K, Madanmohan, Bhavanani AB, Vijayalakshmi P, 13.
Krishnamurthy N. Eﬀect of pranayam training on cardiac function in
normal young volunteers. Indian Journal of Physiology and Pharmacology.
Ravindra P N, Madanmohan, Pavithran, P. Eﬀect of pranayam 14.
(yogic breathing) and shavasan (relaxation training) on the frequency
of benign ventricular ectopics in two patients with palpitations.
International Journal of Cardiology. 2006;108:124-125.
Mayer S. Studien zur Physiologie des Herzens und der Blutgefaesse 15.
6. Abhandlung: ueber spontane Blutdruckschwenkungen. (Studies on
the physiology of the heart and the blood vessels 6. Discourse on ﬂuc-
tuations in blood pressure). Sitz Ber Akad Wiss Wien, Mathe-Naturwiss
Kl Anat 1876;74:281–307.
Bernardi L, Sleight P, Bandinelli G, Cencetti S, Fattorini L, 16.
Wdowczyc-Szulc J, Lagi A. Eﬀect of rosary prayer and yoga mantras on
autonomic cardiovascular rhythms: comparative study. British Medical