Dr.Usha Kiran, MD Journal of Preventive Cardiology Vol.1/No.2 November 2011

1. 85s s sJ. Preventive Cardiology Vol. 1 No. 2 November 2011s s sJ. Preventive Cardiology Vol. 1 No. 2 November 2011
1948 to 1955 and served as a major driving force in the
Framingham Heart Study, which was the first extensive
epidemiologic work carried on to identify risk factors in
coronary artery disease. He was also influential in the
American Red Cross and in establishing the National
InstitutesofHealth.
Paul D. White died on October 31, 1973, at the age of 87
following a second stroke. He was to have received the
Herrick Award from the American Heart Association, but
died before that honour could be conferred. A memorial
service was therefore, held in the Harvard Memorial
Church the next month; there, J. Willis Hurst, M.D., a
former student of White's, delivered a eulogy entitled "I'm
NotThroughYet."
The United States Postal Service honoured White with a 3¢
GreatAmericans series postage stamp in 1986, still on sale
today. The 17-mile bike path around the Charles River in
Boston bearshis name.
-JPSSawhney&SC Manchanda
Sawhney JPS, et al.
Effects of meditation on recovery after coronary artery bypass
surgery
UshaKiran,MD
DepartmentofCardiacAnaesthesia,AllIndiaInstituteofMedicalSciences(AIIMS),NewDelhi,India.
Abstract
Preoperative physical and psychological preparation before
coronary artery bypass surgery is an essential protocol as
anxiety and fear may adversely affect the recovery.
Most of these patients are Type – A personality and do need to
follow lifestyle modification program. This is the time when they
realize the need to adopt relaxing techniques and readily
accept to learn and practice meditation if offered. Meditation is
not only the best way to arouse relaxation response but has
also been found a very successful tool for relief of fear and
anxiety at many cardiovascular centres all over the world.
Attitudinal change and development of ‘will to get well’ by
training and practice of meditation has shown hemodynamic
stability in the postoperative period. Overall hospital stay has
been more comfortable in patients practicing spiritual based
meditation.
Training in Rajyoga meditation of Brahma Kumaris is regularly
given to patients and their relatives in a special meditation
room in the Cardio-Neuro Centre at AIIMS and have gained
enormous success and popularity in reducing postoperative
pain and depression following open heart surgery.
sIntroduction
Stress of coronary artery bypass surgery starts from the
moment surgery is planned. Heart surgery poses not only
the stress to the individual who has to undergo
(CABG) but also to his/ her close
relatives and well wishers. Anxiety and fear prevails in
every thought. Patient may look very calm from outside but
the inside scenario of psycho-immune hormonal response
to anxiety & fear, economic burden, being away from work
etc. is enormous. Usually every one is very well informed
about the surgery being beneficial and pain experienced
would be insignificant. Many people do access internet to
be well informed about CABG. Sometimes this
informationinvokesmorestress thanrelieving.
1 2 3 4
It is well known that stress , anger , hositilty , anxiety and
5
depression are the components of the personality of
patients suffering with Coronary Artery Disease (CAD).
Presences of these factors also affect the outcome of
CABG, psychological distress and uncertainty about future
6,7
is more disturbing than the chest pain. Preoperative
anxiety is a predictor of poor recovery from cardiac
8
surgery. There is a growing body of empiric evidence that
mind-body interventions resulting in personality
modification and lifestyle change effectively reduce
9
anxietyandhostilenature.
Over the last two decades, mind-body medicine has been
used as complimentary to the modern medicine based on
the strong connection between thoughts, feelings and
emotions and their impact on neurological and immune
system. Mind-body interventions in the form of meditation
is the focus of research at many institutes. Meditation
invokes a state of autonomic nervous system that is
Coronary
Artery Bypass graft
Received: 28-09-11; Revised: 13-10-11;Accepted:29-10-11
Disclosures:This article has not received any funding and has no vested commercial interest
Acknowledgements: None
KeyWords
q
q
q
q
q
Preoperativeanxiety
CABG
Meditation
Rajyoga
Relaxationresponse
84

2. 87s s sJ. Preventive Cardiology Vol. 1 No. 2 November 2011
correlated with a reduction in stress reactivity. There is
strong evidence that stress reduction is essential for the
successfuloutcomeofCABG.
In this era of modern medicine, plenty of medications are
available to allay anxiety. Since sedative medicines often
have an effect on blood pressure and respiration, other
options are offered to the patients for pre-surgical anxiety
in addition to small dose of anti-anxiety drugs and
sedatives. Relief of preoperative anxiety and fear has been
attempted with the aid of mind-body interventions like
meditation and relaxation techniques. A very significant
10
and positive effect has been shown by Voss, et al on
anxiety and fear relief before CABG. Meditation can
counter act the flight-or-fight response that floods the body
due to stress hormones cortisol and also shut-down the
parasympathetic system, which normally restores after the
alertis over.
Mehmet, a cardiovascular surgeon from Columbia
Presbyterian Medical Centre in New York City, conducted
a randomized trial on patients for heart surgery by offering
meditation with the help of music and 90 minute
audiotapes. Most of the patients opted for meditation. This
randomized trial has shown better relief of anxiety and
11
reducedpaininthepostoperativeperiod.
Relaxation response was first defined by Harvard
cardiologist, Benson. The relaxation response resulted in a
lower incidence of postoperative supra-ventricular
tachycardia and decrease in anger in patients undergoing
12
coronaryarterysurgery.
Effect on psychological recovery of patients undergoing
CABG has been studied by Ai, et al who found less
depression and general distress in patients where relaxation
13
techniques were used. While Ashton, et al conducted a
prospective randomized trial on patients undergoing
CABG surgery by giving training for mind body
intervention in the form of self hypnosis before surgery and
observed that patients were more relaxed, experienced less
13
pain,andrequiredfewerpainmedication.
Most of the mind body interventions are focussed at
reducing the anger episodes in cardiac patients.Appel, et al
reported a 50% reduction in incidence of post Percutaneous
transluminal coronary angioplasty (PTCA) cardiac events
associated with decrease in anger and depression and
14
avoiding CABG in emergency situation. Preoperative
tachyarrhythmia’s were also significantly reduced.
Significant effect was observed on postoperative pain, and
requirementofanalgesic.
sSuitabletimetooffermeditation
Pre and post surgery is the time when patients show
acceptance if offered to learn meditation. Preoperative
period, especially when there is a long waiting list, the
stress is too high. Patient and the family members should be
able to devote time of at least 45 to 60 minutes each day.
Most of the CABG patients have an average stay of 5-7
days in hospital.After discharge from hospital, majority of
bypass patients are not able to return to work for 4-6 weeks.
This period can be utilized for practice of meditation and
mind management. Meditation as a part of cardiac
rehabilitation is ideally offered the day he/she is diagnosed
to have CAD. Studies have demonstrated positive effects
of complementary therapies given in preoperative period to
15,16
surgicalpatients.
sRajYoga meditation
The Raj Yoga meditation as per the teachings of Raj Yoga
Education and Research Foundation of Brahma Kumaris is
offered to patients and their caregivers or relations. It is
considered as a holistic approach for preparing patients for
surgery. Anxiety and fear alleviation by practical training
of Raj Yoga meditation reduced the incidence of major
depression in the postoperative period. This spiritual based
Raj Yoga has been shown to be associated with increased
well being, meaning in life and confidence on handling
problems and adopting a positive smiling nature, just with
small 3 lesson condensed course given during the hospital
stay.
In elderly group patients (age >65) the incidence of
postoperative depression after CABG was reduced from
48% to 14% by the practice of Raj Yoga Meditation. It is a
very successful tool for converting negative thoughts to
positive by realizing the power of true self and supreme
being. A meditation room inside the premises of the
Cardio-Thoracic Centre at All India Institute of Medical
Sciences (AIIMS) is very useful for provision of peaceful
andsereneambiancetolearnmeditation.
Meditation, a condensed course in the form of relaxation
therapy, spiritual exercises and gear up self healing should
be a part of preoperative preparation programme for the
patients scheduled for cardiovascular surgery and be
continued in the postoperative period. These definitely
improve recovery after surgery, reduce postoperative pain
and suffering, and lower the hospital stay and costs. This
modality focuses on spiritual, emotional and psychological
needsaswellasfulfilsphysiologicalneedstoo.
s s sJ. Preventive Cardiology Vol. 1 No. 2 November 2011
Meditation and CABG
sReferences
1. Frasure-Smith N. In-hospital symptoms of psychological stress as
predictors of long-term outcome after acute myocardial infarction
in men.Am J Cardiol. 1991; 67: 121-127.
2. Kawachi I, Sparrow D, Spiro A 3rd, et al. A prospective study of
anger and coronary heart disease: the Normative Age Study.
Circulation. 1996; 94: 2090-2095.
3. Williams RB. Psychological factors in coronary artery disease:
epidemiological evidence. Circulation. 1987; 76 (suppl):117-123.
4. Sullivan M. LacroixA, Baurn C, et al. Functional status in coronary
artery diseases: a one-year prospective study of the role of
anxiety and depression.Am J Med.1997; 67: 121-127.
5. Januzzi J, Stem T, Pastemak R, et al. The influence of anxiety and
depression on outcomes of patients with coronary artery disease.
Arch Intern Med. 2000; 160:1913- 1921.
6. Begtson A, Herlitz J, Karlsson T, et al. Distress correlates with
degree of chest pain: A description of patients awaiting
revascularization. Heart 1996;75: 257-260.
7. Arthur H, Daniel C, Mckelvie R, et al. Effect of preoperative
intervention on preoperative and post operative outcomes in low
risk patients awaiting elective coronary artery bypass surgery - a
randomized controlled trail.Ann Intern Med. 2000, 133: 253-262.
8. Underwood M, Firmin RK, Jehu D. Aspects of psychological and
social morbidity in patients awaiting coronary artery bypass
grafting. Br Heart J. 1993, 69: 382-384.
9. Ashton C Jr, Whitworth GC, Seldomridge JA, et al. Self-hypnosis
reduces anxiety following coronary artery bypass surgery. A
prospective, randomized trial. J Cardiovasc Surg. (Torino). 1997;
38: 69-75.
10.Voss JA, Good M, Yates B, et al. Sedative music reduces anxiety
and pain during chair rest after open-heart surgery. Pain. 2004;
112: 197-203.
11. Meh mal Oz, Medical Meditation: Say Om before Surgery.
www.time.com/magazine/article/0,9171. last accessed on
January, 2003.
12.Leserman J, Stuart EM, Marnish ME, et al. The efficacy of the
relaxation response in preparing for cardiac surgery. Behav
Med.1989;15:111-117.
13.AiA, Peterson C, Bolling S. Psychological recovery from coronary
artery bypass graft surgery: the use of complementary therapies.
JAlternative Complement Med.1997; 3: 342-353.
14.Appels A, Bar F, Lasker J, Flamm U, et al. The effect of
psychological intervention program on risk of a new coronary
event after angioplasty: A feasibility study. J Psychosomat Res
1997; 43: 209-17.
15.Oz M, Whitworth G, Liu E. Complementary medicine in surgical
wards. JAMA1998; 279:710-11.
16.Hadz A Esmore D, Rowland M, Pepe S, et al. Preoperative
preparation of cardiac surgery utilizing combination of metabolic
physical and mental therapies. Heart Lung and Circulation.
2006;15: 172-181.
Address for correspondence
th
20
Dr. Usha Kiran: Email: dr_ukiran@yahoo.com
Kiran U.
86

3. 87s s sJ. Preventive Cardiology Vol. 1 No. 2 November 2011
correlated with a reduction in stress reactivity. There is
strong evidence that stress reduction is essential for the
successfuloutcomeofCABG.
In this era of modern medicine, plenty of medications are
available to allay anxiety. Since sedative medicines often
have an effect on blood pressure and respiration, other
options are offered to the patients for pre-surgical anxiety
in addition to small dose of anti-anxiety drugs and
sedatives. Relief of preoperative anxiety and fear has been
attempted with the aid of mind-body interventions like
meditation and relaxation techniques. A very significant
10
and positive effect has been shown by Voss, et al on
anxiety and fear relief before CABG. Meditation can
counter act the flight-or-fight response that floods the body
due to stress hormones cortisol and also shut-down the
parasympathetic system, which normally restores after the
alertis over.
Mehmet, a cardiovascular surgeon from Columbia
Presbyterian Medical Centre in New York City, conducted
a randomized trial on patients for heart surgery by offering
meditation with the help of music and 90 minute
audiotapes. Most of the patients opted for meditation. This
randomized trial has shown better relief of anxiety and
11
reducedpaininthepostoperativeperiod.
Relaxation response was first defined by Harvard
cardiologist, Benson. The relaxation response resulted in a
lower incidence of postoperative supra-ventricular
tachycardia and decrease in anger in patients undergoing
12
coronaryarterysurgery.
Effect on psychological recovery of patients undergoing
CABG has been studied by Ai, et al who found less
depression and general distress in patients where relaxation
13
techniques were used. While Ashton, et al conducted a
prospective randomized trial on patients undergoing
CABG surgery by giving training for mind body
intervention in the form of self hypnosis before surgery and
observed that patients were more relaxed, experienced less
13
pain,andrequiredfewerpainmedication.
Most of the mind body interventions are focussed at
reducing the anger episodes in cardiac patients.Appel, et al
reported a 50% reduction in incidence of post Percutaneous
transluminal coronary angioplasty (PTCA) cardiac events
associated with decrease in anger and depression and
14
avoiding CABG in emergency situation. Preoperative
tachyarrhythmia’s were also significantly reduced.
Significant effect was observed on postoperative pain, and
requirementofanalgesic.
sSuitabletimetooffermeditation
Pre and post surgery is the time when patients show
acceptance if offered to learn meditation. Preoperative
period, especially when there is a long waiting list, the
stress is too high. Patient and the family members should be
able to devote time of at least 45 to 60 minutes each day.
Most of the CABG patients have an average stay of 5-7
days in hospital.After discharge from hospital, majority of
bypass patients are not able to return to work for 4-6 weeks.
This period can be utilized for practice of meditation and
mind management. Meditation as a part of cardiac
rehabilitation is ideally offered the day he/she is diagnosed
to have CAD. Studies have demonstrated positive effects
of complementary therapies given in preoperative period to
15,16
surgicalpatients.
sRajYoga meditation
The Raj Yoga meditation as per the teachings of Raj Yoga
Education and Research Foundation of Brahma Kumaris is
offered to patients and their caregivers or relations. It is
considered as a holistic approach for preparing patients for
surgery. Anxiety and fear alleviation by practical training
of Raj Yoga meditation reduced the incidence of major
depression in the postoperative period. This spiritual based
Raj Yoga has been shown to be associated with increased
well being, meaning in life and confidence on handling
problems and adopting a positive smiling nature, just with
small 3 lesson condensed course given during the hospital
stay.
In elderly group patients (age >65) the incidence of
postoperative depression after CABG was reduced from
48% to 14% by the practice of Raj Yoga Meditation. It is a
very successful tool for converting negative thoughts to
positive by realizing the power of true self and supreme
being. A meditation room inside the premises of the
Cardio-Thoracic Centre at All India Institute of Medical
Sciences (AIIMS) is very useful for provision of peaceful
andsereneambiancetolearnmeditation.
Meditation, a condensed course in the form of relaxation
therapy, spiritual exercises and gear up self healing should
be a part of preoperative preparation programme for the
patients scheduled for cardiovascular surgery and be
continued in the postoperative period. These definitely
improve recovery after surgery, reduce postoperative pain
and suffering, and lower the hospital stay and costs. This
modality focuses on spiritual, emotional and psychological
needsaswellasfulfilsphysiologicalneedstoo.
s s sJ. Preventive Cardiology Vol. 1 No. 2 November 2011
Meditation and CABG
sReferences
1. Frasure-Smith N. In-hospital symptoms of psychological stress as
predictors of long-term outcome after acute myocardial infarction
in men.Am J Cardiol. 1991; 67: 121-127.
2. Kawachi I, Sparrow D, Spiro A 3rd, et al. A prospective study of
anger and coronary heart disease: the Normative Age Study.
Circulation. 1996; 94: 2090-2095.
3. Williams RB. Psychological factors in coronary artery disease:
epidemiological evidence. Circulation. 1987; 76 (suppl):117-123.
4. Sullivan M. LacroixA, Baurn C, et al. Functional status in coronary
artery diseases: a one-year prospective study of the role of
anxiety and depression.Am J Med.1997; 67: 121-127.
5. Januzzi J, Stem T, Pastemak R, et al. The influence of anxiety and
depression on outcomes of patients with coronary artery disease.
Arch Intern Med. 2000; 160:1913- 1921.
6. Begtson A, Herlitz J, Karlsson T, et al. Distress correlates with
degree of chest pain: A description of patients awaiting
revascularization. Heart 1996;75: 257-260.
7. Arthur H, Daniel C, Mckelvie R, et al. Effect of preoperative
intervention on preoperative and post operative outcomes in low
risk patients awaiting elective coronary artery bypass surgery - a
randomized controlled trail.Ann Intern Med. 2000, 133: 253-262.
8. Underwood M, Firmin RK, Jehu D. Aspects of psychological and
social morbidity in patients awaiting coronary artery bypass
grafting. Br Heart J. 1993, 69: 382-384.
9. Ashton C Jr, Whitworth GC, Seldomridge JA, et al. Self-hypnosis
reduces anxiety following coronary artery bypass surgery. A
prospective, randomized trial. J Cardiovasc Surg. (Torino). 1997;
38: 69-75.
10.Voss JA, Good M, Yates B, et al. Sedative music reduces anxiety
and pain during chair rest after open-heart surgery. Pain. 2004;
112: 197-203.
11. Meh mal Oz, Medical Meditation: Say Om before Surgery.
www.time.com/magazine/article/0,9171. last accessed on
January, 2003.
12.Leserman J, Stuart EM, Marnish ME, et al. The efficacy of the
relaxation response in preparing for cardiac surgery. Behav
Med.1989;15:111-117.
13.AiA, Peterson C, Bolling S. Psychological recovery from coronary
artery bypass graft surgery: the use of complementary therapies.
JAlternative Complement Med.1997; 3: 342-353.
14.Appels A, Bar F, Lasker J, Flamm U, et al. The effect of
psychological intervention program on risk of a new coronary
event after angioplasty: A feasibility study. J Psychosomat Res
1997; 43: 209-17.
15.Oz M, Whitworth G, Liu E. Complementary medicine in surgical
wards. JAMA1998; 279:710-11.
16.Hadz A Esmore D, Rowland M, Pepe S, et al. Preoperative
preparation of cardiac surgery utilizing combination of metabolic
physical and mental therapies. Heart Lung and Circulation.
2006;15: 172-181.
Address for correspondence
th
20
Dr. Usha Kiran: Email: dr_ukiran@yahoo.com
Kiran U.
86