Link Between Pregnancy Complications and Heart Disease

by Nina

The Kiss by Mary Cassatt

Baxter and I recently read an extraordinary 50-year study Pregnancy Complications and Cardiovascular Disease Death: Fifty-Year Follow-Up of the Child Health and Development Studies Pregnancy Cohort  that was conducted on nearly 15,000 women who became pregnant from 1958 to 1967. The study noted which of the pregnant women had pregnancy complications and then followed all the women through 2011. For those women who had pregnancy complications, the study found a link to death from heart disease before age 60.

We wanted to let you know about this study because of course some of our readers will fall into this category of having had pregnancy complications. We don’t want you to panic, of course. We just want you to be aware of the link between these conditions, and hopefully take a few preventative steps. 

So today I’ll start by telling you about which complications are linked to heart disease, and why. Then I’ll say something about what you should do if you are at risk (Or, what you should help a relative or friend do if she is at risk.)

Which Pregnancy Complications are Linked to Heart Disease?

Pregnancy complications that raised the risk of death from heart disease included:

• High blood pressure before or starting during pregnancy (preeclampsia) 
• Low-birth-weight child
• Early delivery
• A drop in the ability of red blood cells to carry oxygen
• High sugar levels in the urine

According to a co-author of the study, Barbara A. Cohn, PhD, director of the Child Health and Development Studies at the Public Health Institute, all these complications increased the risk of dying from heart disease before 60. Having more than one complication raised the risk even more. Depending on the complication, and the number of them, the risk of death increased by nearly two to seven times. The study concluded:

"The presence of pre- existing hypertension coupled with pre-eclampsia, preterm birth, or SGA birth, strongly predict CVD death. Furthermore, we found that early-onset pre-eclampsia predicts death before age 60."

Why is there a Link between these Complications and Heart Disease?

Apparently the complications themselves aren’t the cause of increased risk of heart disease. Instead, the complications may be a predictor of how well a woman's cardiovascular system can adjust to the demands of pregnancy. So the pregnancy functions as a metabolic stress test for identifying women who are at higher risk of cardiovascular disease later in life.

When you are pregnant, your heart has to work harder to pump enough blood throughout your body and to your unborn baby, as a your blood volume doubles during pregnancy. So pregnancy provides a picture of how well your body is functioning, with complications and preeclampsia showing that a woman’s heart and blood vessels already have problems. While it takes decades for heart disease to develop, these conditions lay the groundwork.

What Should You do if You fall into this Category?

The authors of the study provided advice for doctors rather than patients:

"Physicians should provide early, prompt surveillance and intervention for women with these high-risk pregnancy complications."

and

"We observed combinations of pregnancy complications that predict high risk of death and two new risk markers, glycosuria and hemoglobin decline. Obstetricians serve as primary care physicians for many young women and can readily use these complications to identify high-risk women to implement early prevention."

If you are currently pregnant and experiencing any of these complications, please alert your obstetrician to this study so the doctor can take appropriate actions. 

If you previously experienced any of these complications, take this information to your doctor, whether that is your internist or OB/GYN, and discuss what is the best approach for you. In the meantime, you can support the medical monitoring or treatment you are receiving from your doctor with a yoga practice focused cardiovascular health.

Start by reading our post Heart Health and Yoga for some background information. Then you can check out our yoga sequences for heart health, which are both short and accessible practices. 

The Inverted Heart Health Sequence includes inverted poses because they can have several immediate and long-term influences on your heart and circulatory system. Inversions put your body in a position to take advantage of gravity to assist in venous return to your heart—you flip upside down and gravity pulls the blood back toward your heart and head! They can also have a quieting effect on your nervous system, encouraging a shift from Fight or Flight mode to Rest and Digest mode. Your heart muscle needs both exercise and rest, so a good combination of effort and relaxation in your practice will give your heart a more balanced experience.

The Cardiovascular Heart Health Sequence includes:

Dynamic Yoga Sequences. Linked sequence of poses that move fairly quickly, such as Sun Salutations, gradually warm up your body and your cardiovascular system, both strengthening and stretching the muscles and connective tissue that your body’s blood vessels pass through, both exercising your heart and encouraging more efficient flow through the piping of your system.

Static Poses. Poses that you hold for longer periods increase what is known as the “work load” of your heart, providing a different kind of exercise and challenge for your heart. Those with high blood pressure and diabetes will have to approach these poses with caution and work into the holds very gradually, preferably under the guidance of an experienced teacher.

Gentle Inversions and Restorative Poses. These poses quiet and rest your cardiovascular system and your heart, which is equally important to testing and stressing your system. They allow your heart and nervous system to quiet, and as a result can nicely lower your blood pressure, heart rate and breathing rate.

Pranayama and Meditation Practices. These practices support the effects of the inversions and restorative poses.

If chronic stress is a problem for you, see The Relaxation Response and Yoga for an overview of how yoga helps with stress and a list of techniques to choose from. We also have many posts on insomnia (see Five Tips for Better Sleep, for example). Finally, if you’re struggling with poor eating habits, see Yoga for Healthy Eating. 

See webmd.com for further information. (We can't give you access to the full original study, which Brad obtained for us, but the abstract is at Pregnancy Complications and Cardiovascular Disease Death: Fifty-Year Follow-Up of the Child Health and Development Studies Pregnancy Cohort.)

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Yoga After Heart Surgery for Stent Placement

by Baxter

Back in the late 60s and early 70s, a new surgical treatment for blocked heart blood vessels was being perfected. Known as coronary artery bypass grafting, it allowed doctors to work around the heart’s own blood vessels that supply the muscle of the heart with oxygen and nutrition when they became dangerously plugged with plaque buildup. Patients that previously would have, most likely, suffered severe or life-ending heart attacks were now being surgically repaired and at least temporarily “cured” of their heart blockages. I say temporarily because doctors like Dean Ornish, MD, noticed that many of these patients who had undergone open-heart surgery would return several years later with new blockages in their new plumbing! Most likely, this was due to the fact that they had not changed their lifestyle and dietary habits. 

As early as 1977, cardiologists started trying to treat the blockages in the heart blood vessels without having to crack the chest open, instead threading a catheter into a large blood vessel in the groin area and guiding it up to the heart and into an individual heart blood vessel. Once at the narrowing area of the blood vessel threatening the patient’s heart, a small mesh scaffold, called a “stent,” was slipped into place and gently expanded to reopen the narrowing. This stent was then left in place. 

All this history gets personal for both Nina and me, as we both have had loved ones undergo stent placement for coronary heart disease in the past year. In my case, my family member had just celebrated his 50th birthday, and with little prior warning or symptoms, had a sudden cardiac event at home that required CPR and electric shock to the chest by the EMTs to restart the heartbeat again. Evaluation at the hospital immediately afterwards showed one heart vessel with a blockage and a stent was put in place right away. Follow-up tests showed no permanent damage to the heart muscle from this heart attack—thank goodness!

It has been found that patients who go through “cardiac rehabilitation” programs following stent placement do better down the road than those that don’t. Cardiac rehab involves progressive aerobic activity on treadmill and stationary bikes while having the heart rhythm monitored, for 30 minutes 3 times a week for 3 weeks, then bumped up to 45minutes, 3 times a week for 3 more weeks. In my family member’s situation, he had been very physically active prior to his event, swimming and golfing regularly, and he was anxious to be able to return to those activities. If yoga had been his thing, I suspect that same desire would have been there. So, what are the recommendations about “return to activity” that could guide you as a yogi if you have to have a stent placed? The NIH has the following post-stent recommendations:

“After a stent procedure, [because of the risk of blood clots causing your open vessel to close,] your doctor will likely recommend that you take aspirin and other anticlotting medicines. Patients are told to avoid vigorous exercise and heavy lifting for a short time after the stent procedure. Your doctor will let you know when you can go back to your normal activities. … However, stents aren't a cure for atherosclerosis or its risk factors. Lifestyle changes may include changing your diet, quitting smoking, being physically active, losing weight, and reducing stress. You also should take all medicines as your doctor prescribes. Your doctor may suggest taking statins, which are medicines that lower blood cholesterol levels.”

Interestingly, there aren’t many other warnings I could find about returning to full activities, such as yoga, and no specific warnings about avoiding certain positions, including inverted yoga poses. In fact, a student of mine had his first of four stents placed for angina, or heart pain, starting at age 67 in 2000. He started doing yoga in 2003, which included regularly practicing Shoulderstand (Sarvangasana) at the wall in his new home yoga practice. He has continued to include it since then. He felt pretty certain he had discussed doing yoga with his family doctor at the time, as well as his heart doctor, and was not given any specific restrictions or warnings about yoga in general. 

I would not suggest that this means you should start a vigorous yoga practice that includes a lot a challenging inversions, but would instead suggest a gradual introduction of yoga over the course of time, just as the cardiac rehab is gradually advanced while monitoring for worrisome symptoms. And certainly engage in a conversation with your heart doctor about their views on the safety of your desired yoga program. Also, keep in mind that even a gentle yoga practice, like the one used in the Ornish Heart studies, has been shown to have powerful effects on long term heart health. So you likely have a wide range of options as to the kind of yoga practice you might restart or start for the first time if you find yourself confronted with a new diagnosis of coronary heart disease. If any of our readers have been given different advice by their docs, please write to us about it.

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Heart Health and Yoga: An Overview

by Nina

The Heart by Henri Matisse*

After three years of blogging, even I, the Editor-in-Chief, can't remember everything that’s on our blog. So because someone close to me has developed heart disease and I want to be able to help him, I’ve been—hahaha—reading through my own blog today. At the same time that I’m trying to see which topics we’ve covered so far (nothing on stents that I can see—paging Dr. Baxter Bell!), I’m also trying to get up to speed on some background information by re-reading some of our older posts. So it occurred to me that while I was educating myself on the topic of yoga and heart health, I should share what I find out with you all. After all, the U.S. Centers for Disease Control says that heart disease is the leading cause of death of in the U.S.

In Shari’s post Yoga for Heart Conditions, she provides an excellent overview of what heart disease is and how yoga can help. She says that she believes that:

“yoga can be so effective for the management of heart disease because it is a holistic health approach that takes into account all of the varied systems of the body —in yoga, the body is part of a greater whole. Yoga is also accessible to all who want to practice, no matter what their physical ability may be. And yoga’s powerful stress management tools, including learning to slow down and breathe deeply, have many beneficial effects on heart health. Several scientific studies have now demonstrated conclusively that learning to breath deeply decreases blood pressure and slows down heart rate by stimulating the parasympathetic nervous system (Relaxation Response) and slowing down the sympathetic nervous system (Fight or Flight Response). And once you learn to become mindful of your breath and of how your body can feel when it is in a relaxed state as opposed to a hyper-arousal state, then conscious, healthy eating is a natural sequel of the yogic approach to health. Finally, learning to move your body (which nourishes all the musculoskeletal, respiratory, lymphatic, and circulatory systems) will help improve heart health.”

In Baxter’s post About Yoga for Heart Health, he wrote about how yoga practices help to maintain or improve circulation in the cardiovascular system, which is essential for heart health. He concludes that post by saying:

"Yoga, therefore, can be said to improve circulation by improving blood flow and the return of lymphatic fluids to the heart, reversing the impact of chronic stress on circulation, lowering blood pressure, slowing down or reversing atherosclerosis, improving the heart rhythm and improving overall heart health."

In Baxter’s post Cortisol and Good Health, he focuses in particular on the relationship between chronic stress and health problems, including heart disease. He says:

"But if you are either under constant stress, or your mind is prone to brooding about the past or anxious musings about the future or even negative assessments about the present moment, your adrenals interpret this as an actual stressful event occurring right now, and cortisol gets released into your system. So cortisol levels remain high in the blood stream for greater periods of time, which can result in swelling of the gland itself, and an increased chance of the following negative effects: loss of immunity secondary to shrinkage of lymph glands, increased risk of stomach ulcers, increased risk of hypertension, heart disease and other vascular disorders, excess sugar in the blood stream and more chance of developing diabetes."

While we in the yoga community all know that yoga can help to improve circulation and reduce stress (see The Relaxation Response and Yoga), Baxter also recently posted Yoga and Heart Health: Newest Study about a scientific meta-analysis study Effects of yoga on cardiovascular disease risk factors: A systematic review and meta-analysis, which concluded:

"This meta-analysis revealed evidence for clinically important effects of yoga on most biological cardiovascular disease risk factors. Despite methodological drawbacks of the included studies, yoga can be considered as an ancillary intervention for the general population and for patients with increased risk of cardiovascular disease."

Baxter has even designed two different yoga sequences for heart health, both short and accessible practices.

The Inverted Heart Health Sequence includes inverted poses because they can have several immediate and long-term influences on your heart and circulatory system. Inversions put your body in a position to take advantage of gravity to assist in venous return to your heart—you flip upside down and gravity pulls the blood back toward your heart and head! They can also have a quieting effect on your nervous system, encouraging a shift from Fight or Flight mode to Rest and Digest mode. Your heart muscle needs both exercise and rest, so a good combination of effort and relaxation in your practice will give your heart a more balanced experience.

The Cardiovascular Heart Health Sequence includes:

• Dynamic Yoga Sequences. Linked sequence of poses that move fairly quickly, such as Sun Salutations, gradually warm up your body and your cardiovascular system, both strengthening and stretching the muscles and connective tissue that your body’s blood vessels pass through, both exercising your heart and encouraging more efficient flow through the piping of your system.
• Static Poses. Poses that you hold for longer periods increase what is known as the “work load” of your heart, providing a different kind of exercise and challenge for your heart. Those with high blood pressure and diabetes will have to approach these poses with  caution and work into the holds very gradually, preferably under the guidance of an experienced teacher. 
• Gentle Inversions and Restorative Poses. These poses quiet and rest your cardiovascular system and your heart, which is equally important to testing and stressing your system. They allow your heart and nervous system to quiet, and as a result can nicely lower your blood pressure, heart rate and breathing rate.
• Pranayama and Meditation Practices. These practices support the effects of the inversions and restorative poses.

If chronic stress is a problem, see The Relaxation Response and Yoga for an overview of how yoga helps with stress and a list of techniques to choose from. We also have many posts on insomnia (see Five Tips for Better Sleep, for example). Finally, if you’re struggling with poor eating habits, see Yoga for Healthy Eating. 

I'll be giving my loved one private lessons, starting with initial lessons on managing the stress related to realizing you have the disease and coping with surgery and recovery, and I'm sure I'll have more to say about yoga for heart disease as I learn more about it myself.

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Yoga for Heart Conditions

by Shari

One of the workshops I teach regularly with my colleague Bonnie Maeda is Yoga for Heart Conditions. Bonnie and I believe that yoga can be so effective for the management of heart disease because it is a holistic health approach that takes into account all of the varied systems of the body —in yoga, the body is part of a greater whole. Yoga is also accessible to all who want to practice, no matter what their physical ability may be. And yoga’s powerful stress management tools, including learning to slow down and breathe deeply, have many beneficial effects on heart health. Several scientific studies have now demonstrated conclusively that learning to breath deeply decreases blood pressure and slows down heart rate by stimulating the parasympathetic nervous system (Relaxation Response) and slowing down the sympathetic nervous system (Fight or Flight Response). And once you learn to become mindful of your breath and of how your body can feel when it is in a relaxed state as opposed to a hyper-arousal state, then conscious, healthy eating is a natural sequel of the yogic approach to health. Finally, learning to move your body (which nourishes all the musculoskeletal, respiratory, lymphatic, and circulatory systems) will help improve heart health.

Today I thought I might give you a little background about heart health, share with you some statistics that I find fascinating, and provide an overview of how yoga can help with heart conditions. To start, the cardiovascular system is made up of the heart, arteries, veins and capillaries, and a pulmonary circuit that transports blood to and from the lungs. The system functions to circulate blood throughout the body, bringing nutrients and oxygen to each and every cell as well as collecting waste products from cell metabolism for elimination by the lungs, skin, kidneys and intestines. The system also functions to deliver hormones and enzymes to specific tissues.

The heart is actually a muscular organ about the size of your fist. The outer layer of the heart muscle is called the myocardium. The heart has four chambers and four valves that function as one-way doors to keep the blood flowing in the proper direction. The heart has its own electrical system that triggers each heartbeat, a regular, coordinated cycle causing the chambers to relax and contract and pump blood through the entire body. There is also a separate artery system (coronary arteries) that runs through the myocardium ensuring that the heart itself receives oxygen and nutrients

Various cardiac conditions include;

• Hypertension: higher than “normal” blood pressure
• Hypotension: lower than “normal” blood pressure
• Atherosclerosis: accumulation of smooth muscle cells, lipids and connective tissue inside the inner most layer of the arterial vessels(plaque build up)
• Coronary artery disease: the three major coronary arteries may be blocked or damaged, and there is decreased blood delivery to the heart muscle
• Congestive heart failure: a clinical syndrome where the heart fails to propel blood forward normally, resulting in congestion in the pulmonary and or systemic circulation, and the diminished blood flow to the tissues causes reduced cardiac output
• Heart attack (myocardiac infarction): occlusion of the coronary arteries with death to the heart muscle cells.
• Dysrhythmias: faster than normal heart rate (tachycardia), slower than normal heart rate (bradycardia), irregular heart beat.

Here are some interesting statistics:

• Heart disease is the number 1 killer in the modern world and more women than men suffer heart attacks.
• Hypertension (high blood pressure) affects 1 in 6 people in the western world and 1/3 of them are unaware they have hypertension.
• Angina (heart pain) attacks most frequently occur between 10-11am.
• Most heart attacks occur on Mondays and more occur in the winter months.
• Emotional stress will most often precipitate heart attacks in women.
• Physical stress will most often precipitate heart attacks in men.
• Dissatisfaction with one’s life, loneliness and unhappy marriages (or relationships) can also increase cardiac risk factors.
• Inflammation, like gum gingivitis and rheumatoid arthritis, is a major factor in heart disease.
• Stress hormones will raise blood pressure and increase heart rate with increasing strain on the heart itself and increasing its need for oxygen.
• Stress will often cause coronary muscle spasms. It takes the body three hours to recover after an episode of intense anger.

So how does yoga fit in with the management of heart conditions? What stimuli do we want to encourage to soothe the nervous system, which in turn affects all the major organ systems in the body? In her post, The Relaxation Response and Yoga, Nina mentioned all the different ways we can use yoga to switch our nervous systems to Relaxation mode, including meditation, breath practices, restorative poses, Relaxation pose and yoga nidra. Deep, slow breathing, including ujjayi breathing and alternate nostril breathing, is found to be extremely effective in calming down our central nervous system. Please refer to Nina, Baxter, and Timothy’s excellent posts on the breath.

Additionally, yoga poses, including both partial and full inverted poses, that stimulate the baroreceptors naturally reduce blood pressure and show the heart rate. Please refer to all the posts that Nina, Baxter, and I have written about what baroreceptors are and how they may be modulated by positional changes of the body. Although there is some disagreement among various sources on which poses to avoid and which to include when trying to manage hypertension (essential idiopathic hypertension), the poses most frequently recommended for their calming benefits include:

Inversions

• Relaxation pose (Savasana) with legs on a chair
• Legs Up the Wall pose (Viparita Karani)
• Supported Bridge Pose (Setu Bandha Sarvangasana)
• Headstand (Sirsasana), if it is already part of your practice and is comfortable for you
• Shoulderstand (Sarvangasana) if it is already part of your practice and is comfortable for you

(See All About Supported Inverted Poses for more information)

Forward Bends

• Seated Forward Bend (Pascimottanasana)
• Head-Knee Forward Bend (Janu Sirsasana)
• Other forward bend variations

(See for Soothing Yourself with Forward Bends for more information.)

Now some of you may read this list and say, “ I can’t do any of those inversions” or “ I can’t do any of those forward bends.” But the key principle here is how might you modify these poses so you CAN safely do them when considering all the other medical conditions you might also have. For example, propping yourself higher in a seated forward bend, as shown below, can make the pose accessible (and safe) for you.

Everyone can sit on a chair and drape their bodies onto a table or desk for a supported forward bend. And even if you can’t do a classical inversion, everyone can modify Legs Up the Wall pose. It can easily and accessibly be done in bed if there is an available wall for you to put your legs up on or you practice Easy Inverted Pose, which is a bent knee version of Legs Up the Wall pose.

Again the intention is to practice safely and wisely and to try not to put up barriers to prevent yourself from practicing daily.

I’d like to let our San Francisco Bay Area readers know about an upcoming workshop on this topic that Bonnie Maeda, RN and I are doing on December 21, 2013 at Brentwood Yoga Studio in honor of the winter solstice! In this three-hour workshop we’ll be discussing general cardiac physiology and actions, and how the practice of yoga can be an adjunct to self care and health management.

Happy Solstice and be well.

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Chronic Stress: An Introduction

by Nina

Wounded Bird by Brad Gibson

An ongoing theme that we’ll be exploring in depth on this blog is the negative effects of chronic stress on long-term health and the need for stress management as an important aspect of healthy aging. So perhaps it’s a good time for me to define exactly what we mean by “chronic stress” and to let you know a little about why it is such a serious problem.

I learned about dangers of chronic stress the hard way. Back in the early nineties, I had a job as the documentation manager and lead technical writer at a software start-up company, while at the same time I was raising two children. As you might imagine, the pressure was intense as our small company struggled to meet our first deadline, the first test of the product by real customers (who needed my manuals to teach them how to use the product!). As the deadline approached and I started working overtime, I began having difficulty sleeping. I also started losing weight because the stress made me so feel nauseated that I lost my appetite. Eventually I was so anxious, exhausted and nauseated that even though I met my deadline (and the company went on to success), I couldn’t bounce back to normal health. It took a year and half of therapy, medication, and lifestyle changes to recover completely.

Feeling stressed is not always a bad thing, however. It’s your body’s normal response to perceived danger or extreme physical activity (often called the “fight or flight response”), which is vital in keeping you safe and active. When you encounter a stressful situation, whether it is a grizzly bear or a stack of tax forms, your body releases hormones (adrenaline and noradrenaline) to provide you with the energy and alertness needed to cope with the situation. And anyone who has almost been run over an SUV knows the feeling: heart racing, rapid breathing, gut clenching. This is because in stress mode, your nervous system stimulates your organs and mobilizes energy by: 

• raising your blood pressure 
• increasing your heart rate and the blood supply to your skeletal muscles (and away from your gut) 
• dilating your pupils and bronchioles, providing improved vision and oxygenation 
• generating needed energy by breaking down sugar and fat stores for immediate use 

Between stressful situations, your body needs to rest, recover, and acquire new energy, so your nervous system responds by:

• lowering your blood pressure 
• reducing your heart rate, diverting blood back to the skin and gastrointestinal tract 
• contracting your pupils and your bronchioles for reduced oxygenation 
• stimulating your salivary gland secretion, accelerating digestion, and promoting normal movement of food through the gut 

But what if the stress is long term? When you almost get hit by a car, escape from a bear or finish your taxes, the incident is over quickly and you bounce back to normal soon after. But if the stress is ongoing or “chronic,” maybe because of continuing job pressures (like mine at the software company), marriage problems, health problems, and so on, your nervous system is continuously on the alert and this can overtax your body potentially causing:

• heart disease 
• hypertension (high blood pressure) 
• insomnia and/or fatigue 
• digestive disorders 
• headaches 
• chronic anxiety or depression 
• weakened immune system 

(Hmm, I just counted, and it seems I developed almost half of those symptoms, rather impressive in a weird sort of way.)

Of course, these symptoms are not only unpleasant but will seriously compromise your long-term health if you can’t manage to bring them under control. In addition, several age-related diseases, such as Alzheimer’s, Parkinson’s, and Diabetes are exacerbated by stress, and some theories of aging itself (such as the telomere theory I discussed last week) propose stress as a factor in the aging process itself.

I hope you’re not getting too stressed out by reading all of this! I credit yoga with helping me stay well since that breakdown. And in the coming weeks, we’ll be offering many different alternatives for managing your stress even as you take on the many challenges that life has to offer.

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