One mid-november afternoon a few years ago, Deane Delmas returned to work from a lunch break with a throbbing pain in her arm. A colleague called the on-site nurse, who took her blood pressure and found it within normal range. But when the 72-year-old social worker still continued to complain of the pain, the nurse called her longtime physician. "Rush Deane to the emergency room," the doctor told her. "She could be having a heart attack."
A close friend packed her into the car. "She drove me to the emergency entrance and then went out to park," Delmas recounts. "By the time she came back, everything was code red. I'd passed out and flatlined for a long time. They used CPR, defibrillators, you name it. They thought they were going to lose me."
The doctors sent her to another Austin, Texas hospital, one that specializes in heart treatments. Using a procedure called angioplasty—in which a small balloon is inserted into the artery to open blockage and improve blood flow—the staff there was able to save her life. A couple weeks of rehabilitation later, they discharged Delmas with a short list of suggestions: Eat right, exercise, and take cholesterol-lowering drugs.
The story would have ended there, as it does for the countless other Americans who manage to survive cardiac arrest, if it weren't for Delmas's curiosity. Already a healthy eater and an exercise fanatic by normal standards (she completed a marathon in Alaska the year before), she felt something was lacking from the prescription. "After I got back on my feet again, I began to look at my schedule," she says. "It was all assertive, aggressive—lifting weights, brisk walking, and the like. Something was missing."
Stress reduction turned out to be the needed ingredient, and yoga fit the bill. "I didn't realize I carried so much tension throughout my body until I took my first yoga class for cardiac patients," she says. "I learned that correct breathing, nice and deep with long exhalations, would eventually bring my hypertension down." Indeed, Delmas's blood pressure readings, which once spiked dangerously high at periods throughout the day, now told a different story. "I keep a daily record at home. These days, rather than jumping up and down, the numbers have evened out to a healthy range."
To say that yoga has found its place in the field of cardiology would be a stretch. After all, most doctors don't even mention it to their high-risk patients, as Delmas later found out. But it might just be a matter of time, given the revolution underway in heart disease care as it applies to women. The number one killer in the United States, cardiovascular disease has long proven a gender-blind threat. But for reasons ranging from inadequate research to lack of outreach to simple gender bias, both doctors and their female patients have been slow to take it seriously. Sobering statistics and updated gender-specific research, though, have recently shed new light on how and why this disease affects women. The biggest surprise? Now more than ever, all signs point to yoga as one of the best ways for women (and men) to take charge of their cardiovascular health.
Breaking the Mold
Misperceptions run deep when it comes to our hearts. In a recent poll taken by the American Heart Association (AHA), only 8 percent of women named cardiovascular disease as their biggest health concern. But approximately one-half will die from it, as opposed to other threats like breast cancer, which claims one in 27. And confusion does not stop with the patients. Many doctors, too, have remained in the dark about how this disease threatens 50 percent of the population.
Cardiologist Nieca Goldberg, M.D., chief of cardiac rehabilitation and chief of the Women's Heart Program at Lenox Hill Hospital in New York, offers a poignant example. Speaking in front of a group of medical students in the early 1990s, she listened with surprise to the response her co-speaker, a senior cardiologist, gave to a question from the audience. Asked whether women were harder to treat than men, he replied, yes. "They hem and haw," he complained, "and just don't come out and tell you when they have chest pain."
"Well guess what?" Goldberg says, still annoyed years later. "Women don't tend to get chest pain. Women's symptoms of heart attack may be much different than men's. But until only five years ago, all the research had looked at men; women's symptoms have long been viewed as 'atypical.' "
In fact, heart problems in women are different from those in men, beginning with the warning signs. While chest pain, tightness, and pressure mark the classic signs of heart attack in men, women need to watch for other signals—back pain, nausea or dizziness, lower chest and/or upper abdominal discomfort, unusual fatigue, or shortness of breath. You can often distinguish these symptoms from common everyday aches and pains by the circumstance. "When they relate to the heart, warning signs often start when you exert yourself—and after a while, the pain can sometimes get so bad that it comes at rest or in sleep," Goldberg says. "The key is to get checked out when you first suspect something's wrong."
The difference between the sexes even extends to actual traumas like cardiac arrest. "The model we have for a heart attack—the tube gets clogged over time, blood can't get through, heart attack ensues—just isn't the norm in women," says Mehmet Oz, M.D., a New York cardiac surgeon and director of the Columbia Presbyterian Medical Center's Heart Institute. "Ninety percent of arteries in men who have heart attacks have calcium buildup, or plaque. For women, it's only 30 percent."
So what's behind the heart failure? "In women, the tube will often have a spasm and shrink to become a little cappellini rather than a big linguini," Oz says. "The spasm interrupts the flow of blood into the heart, which damages the muscle."
Hormones also play a larger role in women. Estrogen provides some immunity against heart disease, and women in childbearing years have ample amounts. The hormone helps keep arteries supple and even widens blood vessels. But as estrogen levels decrease with the onset of menopause, arteries begin to harden, and blood pressure rises. That's why you see a sharp jump in the rate of heart attack cases in the postmenopausal years of 55 to 65. (Until recently, hormone replacement therapy was hailed as a good solution to the menopausal estrogen drop. Unfortunately, it has since been shown ineffective in preventing heart disease.)
An Ounce of Prevention
At this point in the evolution of modern cardiology, Western medicine truly has the best to offer in acute care. Computerized defibrillators can shock your heart back into action when it falters; nonsurgical bypass procedures heal with catheters instead of knives. All manner of modern tests and devices catch otherwise undetectable threats. "Physical events are quite obvious to the Western mind," says Oz. "We do well when it comes to organ-based care and tangible problems like unstable plaque, acute blockage of an artery, and so forth."
The problem is there is much more to it than that. Consider the case of Sheila Rosenfield. With the help of state-of-the-art diagnostics, doctors determined that the Texas woman's right coronary artery was 99 percent blocked. "They wanted me to lose weight, watch the saturated fats, exercise, and keep my LDL cholesterol levels down with the help of prescribed statins [cholesterol-lowering medication]," Rosenfield says. But heeding their guidelines still didn't address a major source of her condition: stress. The wife of an 82-year-old man with multiple ailments, Rosenfield was on-call around the clock. Returning to her responsibilities without recourse would continue to compromise her heart's health.
Like Delmas and a growing number of other heart patients, Rosenfield turned to yoga and found that she spent much less time worrying about her health. The fact that she had access to yoga for cardiac health sponsored by a hospital is testament to the inroads yoga has made in the medical community. When Dean Ornish, M.D., published his groundbreaking study in 1990 showing that lifestyle changes—including yoga—can reverse heart disease, he paved the way for yoga's acceptance in a field that depends on clinical proof. Many doctors have come to accept yoga as having a place in prevention, with a growing number of hospitals offering it as part of cardiac rehab. Meanwhile, hundreds of nurses and doctors are learning yoga techniques from teachers like Nischala Devi, who collaborated with Ornish to develop the yoga component in his original study and now teaches yoga instructors her own yoga for the heart program.
But even with these successes, the doctors who readily endorse yoga are still few and far between. "It's easier to prescribe things in a pill form, given the number of patients we have and the amount of time in the day," says Oz, whose book Healing from the Heart (Dutton, 1998) makes an impassioned case for complementary medicine. "It's just human nature. It takes time to talk about stress. Just to introduce the idea, especially to a patient who has never thought about it, would take hours we don't have."
What sets the Ozes, Goldbergs, and Ornishes apart from other doctors, however, is their insistence on finding a way. "I never had time to explain the mind-body connection," Oz adds, "but I felt I had an obligation to do it." So he launched the Complementary Care Clinic at Columbia Presbyterian, where patients explore mind-body relationships through yoga and other holistic paths. "Now I can say, 'Here's your surgery, here are some pills, but in addition, here's the Complementary Care Clinic.' "
Whether you have an enlightened health-care provider (who also happens to be covered by your insurance plan) or one who plays solely by the AMA rulebook is sometimes a matter of chance. The good news is that you don't need to obtain anyone's permission to begin yoga for heart disease prevention. You also don't have to choose between the yogic path and the allopathic. If your doctor suggests yoga, great. If not, you'll still find that yoga can help you accomplish what the doctor does order.
Eat right. Chances are you've heard all the dietary watchwords by now. Certain fats, such as the saturated kind-those that stay solid at room temperature, like butter, cream, and margarine—can raise LDL ("bad") cholesterol levels. Sources like the Food and Drug Administration advise that fats consume 10 percent or less of your diet to reduce your risk of coronary heart disease. On the flip side, complex carbohydrates—such as vegetables and fruits, whole grains, peas, and beans—provide basic fuel, plus a dollop of heart-healthy antioxidants—and none of the drawbacks of processed food. You have probably also heard nutritionists discuss portion size: Supersizing is bad; eating in moderation is good.
But it's not always easy to put knowledge into action. Charles MacInerney, a yoga teacher who leads classes at the Hearts and Minds Cardiac Rehabilitation Clinic located at the Austin Heart Hospital, understands this from a yogic standpoint. He takes issue with the tendency of health experts to emphasize what we can't eat. "This leads to internal conflict, resistance, and suppression," he says. "I favor a positive approach, one that requires tuning inward.
"After you've eaten your fill of healthy foods, if you still want ice cream, take a moment to determine whether you're really hungry or trying to satisfy an emotional need," MacInerney advises. Maybe you are bored, lonely, or still reeling from a bad day at work. Recognize that you need to do something nice for yourself and eat with self-compassion instead of guilt. When you eat with this awareness, the deeper emotional needs are satisfied, often with a single mouthful.
"It's almost classic Krishnamurti," MacInerney adds, referring to the famed Indian philosopher and author. "Rather than controlling the mind with negative messages about food, practice detached observation. This kind of mindfulness will eventually engender a deep awareness of how you might be using food for comfort."
Exercise. It's difficult to pick up a newspaper without seeing health reminders-in this case, about getting your 30-minutes a day of moderate, heart-pumping movement. And here again, your greatest challenge is internal resistance, although it manifests differently in men and women. "When you ask patients why they don't exercise, men will say they don't have the time," says Oz. "But women, they often feel they're not important enough."
This translates into a reluctance to carve out time for exercise. "Many women work outside the home, doing the same type of work that men do," explains Devi. "Then they come home and begin their other career, taking care of kids, cleaning, cooking, and so on. It's too much pressure." When it comes time to choose between a workout or emptying the dishwasher, household efficiency often triumphs.
Here yoga stands out in two ways. Some styles, such as vinyasa flow and Ashtanga, provide the aerobic movement crucial for a healthy heart. In addition, time spent on the mat, no matter what the style, enables you to approach any workout, from skiing to spinning, with increased awareness.
"I used to watch people walking on the treadmill while talking or watching TV," says MacInerney of a cardiac rehab program. "They were just mentally passing time until the exercise was done." He sees a big difference in his current program, which weaves mind-body integration into every aspect-including fitness. "Lessons learned in yoga can help you approach exercise with awareness and mindful attention." Rather than seeking to distract the mind during exercise, you immerse your mind in the body, moving away from discomfort, exploring healthy sensations, all the while keeping attention on the breath.
Break bad habits. Addictions of all sorts, whether to certain foods, work, or cigarettes, can contribute to cardiovascular problems. "Yoga can help us build in time for deep relaxation," explains Devi, "one that brings a return to homeostasis, the point where everything comes back into balance." While a single yoga class won't cure your desire, say, to smoke, consistent practice with an emphasis on the breath just might. Says Devi: "An exploration of all levels of the being, going through the different steps of the subtle body, will help unmask—and help you work through—the sources of the habit."
Reduce stress. This is more of a gray area, as some cardiologists still don't view stress as being on par with other heart-jeopardizing risks, like a high-fat diet. And while the AHA acknowledges that stress may contribute to other risk factors, like smoking or physical inactivity, the organization states: "Current data don't yet support specific recommendations about stress reduction as a proven therapy for cardiovascular disease. . . . More research is needed."
However, many doctors and researchers are not holding their collective breath for yet another definitive study to arrive. They are moving forward with the conviction that stress reigns paramount among heart disease causes—especially in women.
According to Oz, emotional stress is far more likely to precipitate cardiac arrest for women than physical stress, which was more of a factor in men. Emotional stress often invites an adrenaline rush that causes a rise in blood pressure and heart rate. For women already battling coronary artery disease, this jump can trigger a blood flow shortage to the heart and increase the risk of death.
Given the innumerable emotional triggers that occur almost every day, stress is clearly a problem to reckon with for your health's sake. And the first place to begin—as yoga does—is with the breath. A healthy heart does not actually beat in a perfectly even rhythm. It gently accelerates when you inhale and slows when you exhale. The emphasis on a complete exhalation—part of any yoga class—has a sound basis in heart science. With shallow thoracic or reverse breathing, the heart never gets a break, explains MacInerney. "Yogic breathing acts like a metronome that helps the heart slow down and slip into a gentle, natural, wave-like pattern. If you forget to breathe or have irregular, jerky, or unsteady breathing, it's like a conductor that can't keep time," he says. "The heart can't afford to follow an unsteady rhythm and so strikes out on its own, resulting in little or no coordination between breath, heart rate, and blood pressure."
Specialized yoga for cardiac health classes like MacInerney's aim, among other things, to restore a heart rate variability that is consistent and stable. But many styles of yoga achieve the same goal. "When your inhalation is longer than your exhalation, it stimulates the sympathetic nervous system," explains MacInerney, referring to the nerves that raise heart rate and blood pressure in preparation for action. "When the exhalation is longer, the parasympathetic system, which lowers the heart rate and blood pressure, takes over. Breathing patterns in Pranayama and yoga work with controlling the ratios of these two systems."
With too much sympathetic stimulation, you have lots of energy, but you are pulled in too many directions. However, with too little, you can't get off the couch to change channels. "Most of us swing from one extreme to the other," says MacInerney. "Yoga helps us achieve balance." (He warns, though, that heart disease patients should never try to manipulate breath without supervision.)
While any time on the mat can help you de-stress, Devi advocates an easy-does-it approach—one that links body, breath, and mind. "People tend to do the yoga practice most akin to their own temperament. Those prone to heart problems often have the classic Type A aversion to doing things slowly. They want to push, push, push.
"At the Ornish program, some participants had a difficult time with the slow and gentle pace, but this was the only way they could look for signals of pain and begin to heal. Being conscious of the way they practiced yoga helped influence the way they lived their lives."
At times it can seem like the odds are stacked against women when it comes to a healthy heart. Atherosclerosis begins as early as the teen years or 20s. The risk of women dying from a heart attack in their 30s is higher than it is for men the same age. Come menopause, the risk of coronary problems—especially heart attacks—dramatically increases. But in the face of these odds lies the proven fact that you can substantially reduce your risk every step of the way. Just as simply brushing your teeth can decrease your chances of needing a root canal, time spent on the mat can make a visit to the operating room much less likely.
"We've achieved the American dream and it's killing us," says Devi. Instead of striving, she suggests engaging in acts that feed the heart. Put your health first. Acknowledge what makes you tick. Explore how your life choices affect mind and body.
"We have a long way to go when it comes to slowing down," she adds. And that's exactly what needs to happen to counter heart disease. As Deane Delmas says of her heart scare, "I ate well all my life. I exercised. I never thought it would happen to me." What her busy schedule did not allow, however, is the precious commodity so many women lack today: time to exhale. It's one of the many gifts yoga offers for healing the heart.
Jennifer Barrett is editor of The Herb Quarterly and has written for Vegetarian Times and Delicious magazine. She lives in West Hartford, Connecticut.