Immediate Effect of Sukha Pranayama on Cardiovascular Variables in Patients of Hypertension

Abstract

Unlabelled:
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. This 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. This 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. This may be due to a normalization of autonomic cardiovascular 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.

Full text

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.
Research
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.
ananda@icyer.com.

74 INTERNATIONAL JOURNAL OF YOGA THERAPY – No. 21 (2011)
Background
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.
Methods
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.
Participants
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.
Pranayama Intervention
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.
Measurements
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.
Results
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
Discussion
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.
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