Practising yoga is associated with symptom improvement and better cardiac outcomes in patients with heart failure, according to a recent study. The new findings documented significant improvements in a range of outcomes among those who practised yoga – focusing on breathing, meditation, and relaxation – as well as taking standard medication compared with those who took medication alone. While previous studies have shown the short-term benefits of yoga in patients with heart failure, this study provides new information about the long-term effects.

“Patients who practised yoga on top of taking their medications felt better, were able to do more, and had stronger hearts than those who only took drugs for their heart failure,” said study author Dr Ajit Singh of the Indian Council of Medical Research, Manipal Academy of Higher Education, India. “The findings suggest that yoga can be a beneficial complementary therapy in patients with heart failure.”

Heart failure carries significant morbidity and mortality, and can have devastating impacts on quality-of-life for the large number of those diagnosed, with the disease affecting more than 64 million people globally. In Ireland, heart failure is more common than most cancers and represents a major public health and economic burden. There are currently more than 90,000 people across the country living with heart failure and over 10,000 new cases are diagnosed annually. Approximately 2 per cent of people in Ireland have symptomatic disease, and this prevalence rises to 10 per cent among adults over the age of 75 years. A further 2 per cent are estimated to have asymptomatic left ventricular systolic dysfunction. Individually, these patients attend general practice around 14 times a year.

The study included 85 patients with heart failure aged between 30 and 70, 82 per cent of whom were male, from the cardiology outpatient department of Kasturba Hospital in Manipal, India. All participants had undergone a cardiac procedure within the past six months to one year and were taking guideline-recommended heart failure medications. The average age of participants was 49 years. The study enrolled patients with New York Heart Association (NYHA) Classification III or less. Those with class IV were excluded.

In a non-randomised fashion, 40 patients were assigned to the yoga group and 45 patients were allocated to a control group. All participants continued taking guideline-recommended heart failure medications throughout the study.

Experienced faculty in the hospital’s Department of Yoga demonstrated pranayama (yogic breathwork), meditation, and relaxation techniques to patients in the yoga group. Participants were supervised for one week and then advised to continue self-administered yoga at home once a week for 50 minutes. Patients spoke to an instructor after each home session to monitor their progress.

All participants in both groups were assessed at baseline, six months, and one year using echocardiography. The measurements included left ventricular ejection fraction and assessment of right ventricular function. The researchers also examined blood pressure, heart rate, body weight, and body mass index. Symptom burden and the ability to do ordinary activities such as walking and climbing stairs were assessed using the NYHA classification system.

Patients in the yoga group had greater improvement in all variables at both time points compared with the control group. The yoga group demonstrated significantly greater improvements in all measurements at six months and one year relative to baseline.

Dr Singh said: “Patients who did yoga had healthier hearts and were more able to carry out ordinary activities such as walking and climbing stairs than those who only took medications. Patients with heart failure should speak to their doctor before starting yoga and should then receive training from an experienced instructor. Prescribed medications should be continued as before. Yoga may be unsuitable for heart failure patients with severe symptoms, who were excluded from our study.”

The abstract ‘Impact of yoga therapy on long-term outcomes in heart failure patients using functional and echocardiographic parameters’ was presented during the session ‘Chronic heart failure – treatment 16’ at Heart Failure 2024, a scientific congress of the European Society of Cardiology, which took place 11-14 May at the Lisbon Congress Centre, Portugal, and online.

A new digital initiative is being launched for cardiology and respiratory patients at St Vincent’s University Hospital, Dublin, and University Hospital Limerick. Virtual wards are expected to offer a safe and efficient alternative to hospital stays and support patients who prefer to receive expert hospital care through monitoring and treatment in their own homes. The virtual ward service may be offered to appropriate hospital inpatients with a respiratory or cardiac condition that are medically stable, but require ongoing monitoring and care prior to formal discharge.

HSE Chief Clinical Information Officer Prof Richard Greene noted that virtual wards are “a new health innovation that has emerged internationally”. He also said: “Central to the National Virtual Wards Programme is the empowerment of patients to be active partners in managing their health and wellbeing. Patients remain under the care of the consultant-led team that provided their care in the hospital and will have a dedicated team monitoring their care 24/7, while they are in the comfort of their own home.”

Healthcare teams will work with patients, and their families or carers if appropriate, to assess whether individuals might be suitable to be treated through the virtual ward service. A member of the clinical team will explain how the service works and why they think it might be a suitable option, and will also ensure patients/carers receive adequate education and training regarding any equipment they will be given. Once a patient is transferred to the virtual ward service, they remain under the care of the consultant team that provided their care in the hospital.

A personalised care plan will be agreed between the patient, their family/carer, and consultant-led care team, and they will establish the best ways to make contact, as well as what to do if the patient feels unwell. Care will continue to be reviewed 24 hours per day, seven days a week by their consultant-led care team. The virtual ward team will be automatically alerted by the monitoring technology if the patient’s readings worsen, or if they are not responding to treatment as expected. Following completion of the patients’ treatment and care, they will be discharged by the consultant-led care team from the virtual ward.

Maureen Gilbert, patient representative on the Virtual Ward Steering Group, described the virtual wards initiative as “a really positive development”, and said it will “offer great potential for patients and their empowerment”. She added: “Virtual wards can support enhanced recovery, and there’s more quality one-to-one communication between patients and their care team. Research shows that patients who recover at home experience less of the stress and anxiety that can sometimes be associated with a hospital stay. There are lots of other benefits too – lower risk of hospital-acquired infection and loss of muscle strength. People who join virtual wards can be more active partners in their own healthcare and they are less likely to need another inpatient hospital stay in the near future.” The national Virtual Wards programme is a collaborative initiative bringing together stakeholders from across the health service including eHealth Ireland, the National Clinical Programme Respiratory, the National Heart Programme, St Vincent’s University Hospital, and University Hospital Limerick.

People born with a congenital heart defect (CHD) are living significantly longer due to the steady progress in medicine and surgery. As such, regarding the whole population of individuals currently living with a CHD, adult patients (ACHD, adult congenital heart disease) outnumber newborns and children affected by the same condition (70 per cent vs 30 per cent).^1,2

Many women can develop strong urges to start a family as they grow older. Unfortunately, cardiac disease is still the main cause of death in pregnant women. Cardiovascular diseases complicate 1-to-4 per cent of all pregnancies and about 80 per cent of those diseases are congenital.^3,4

Pregnancy is characterised by many significant haemodynamic changes such as raised circulating blood volume, increased stroke volume and maternal heart rate, and decreased peripheral vascular resistances.⁵ As such, it can be really challenging being pregnant while ventricular systolic function is reduced, pulmonary pressure increased, or with a circulation supported by a single ventricle. Moreover, foetal mortality is also raised, with an average miscarriage rate of approximately 15 per cent. This in turn can reach a peak of 40 per cent in those with a single ventricle physiology corrected according to the Fontan procedure or in those who are cyanotic.⁶ Again, the risk of CHD recurrence cannot be ignored, mostly for pathologies involving the left and right ventricular outflow tracts, as well as atrial and ventricular septal defects.⁵

The ROPAC registry

The vast majority of information regarding ACHD women who are pregnant is from the Registry of Pregnancy and Cardiac disease (ROPAC), which was established in 2007 with the involvement of many centres, mostly European ones. More than 6,000 pregnant women have been enrolled so far. Over half of them have ACHD (57 per cent), whereas 29 per cent are affected by valvular disease.⁷ The ROPAC shows that maternal mortality is higher in patients with pulmonary arterial hypertension (+0.6 per cent compared to the general population). Heart failure was observed in 11 per cent of the sample and significant arrhythmias in 2 per cent. The main risk factors for maternal complications during pregnancy are pre-pregnancy heart failure with a functional class New York Heart Association (NYHA) >2, systemic ventricle ejection fraction less than 40 per cent, modified World Health Organisation (m-WHO) class of risk IV, and anticoagulant therapy.⁷

Risk stratification

Maternal and foetal risk of adverse events should be assessed before becoming pregnant.⁸ Many scoring systems have been proposed in the field. The most useful of them is the m-WHO classification, which has been promoted since the release of the European Society of Cardiology Guidelines for the Management of Cardiovascular Diseases during Pregnancy. All maternal risk factors have been taken together, including background and comorbidities.^9,10 Four risk classes have been identified according to the increased risk:

– m-WHO I: Includes very low risk pregnancies. One or two examinations during pregnancy are enough;

– m-WHO II: Pregnancy is at low-to-moderate risk. The suggested follow-up consists of an examination every three months;

– m-WHO III: There is a significantly increased risk of maternal mortality or severe morbidity. The rate of adverse events is 19-to-27 per cent. Pregnancy is not recommended. If the patient wants to proceed with pregnancy at her own risk, she should be seen every month or two months;

– m-WHO IV: The risk of maternal mortality or severe morbidity is extremely high. The rate of adverse events is 40-to-100 per cent. Pregnancy is contraindicated. If the patient wants to proceed with pregnancy at her own risk, she should be seen every month or two months.

All the four m-WHO risk classes are strongly correlated with the risk of maternal, foetal, and obstetric complications.⁹ Pregnant women with m-WHO risk class I may not need to be managed in a tertiary care hospital, while patients with m-WHO risk class II or higher should always receive care in this type of setting. Delivery should take place in a hospital setting equipped to provide adequate support to both mother and infant.¹¹ Undergoing pre-pregnancy exercise stress testing has been suggested to identify ACHD women at increased risk of cardiac complications. In fact, chronotropic incompetence during exercise is an independent predictor of adverse events such as heart failure and arrhythmias in females who fail to adequately increase heart rate on exertion.¹²

Counselling and multidisciplinary team involvement

Counselling plays a pivotal role in ACHD women who are pregnant to help both the women and the couples in coping with stressful situations. It can be divided into genetic, cardiological, and obstetric counselling, which in turn requires the involvement of a multidisciplinary team (gynaecologist, midwife, cardiologist, anaesthesiologist, neonatologist).¹³ This is in order to inform the woman/couple about the maternal and foetal risk along with the risk of obstetric complications.

Cardiological counselling is quite complex and should be based on a personalised, ‘tailored’ approach with the goal of planning pregnancy.¹⁴ It is very important to discuss becoming pregnant before any worsening of clinical conditions occurs and to avoid eventually fixing any residual complication before getting pregnant.

Again, in ACHD women with a risk class of risk m-WHO IV, pregnancy should be strongly discouraged.⁵ Ideally pre-conception counselling, especially for moderate-to-high risk ACHD, should start in adolescence, including providing information about contraception. ACHD women, even those with complex CHD, are often asymptomatic or have few symptoms and assume there is no contraindication regarding pregnancy.¹⁵ Major cardiac complications during pregnancy include onset of arrhythmias, heart failure, fainting episodes, chest pain, and thromboembolic events (notably in women with mechanical heart valves).¹⁶ Generally speaking, valvular insufficiency, even when severe, is well tolerated during pregnancy, since peripheral vascular resistance (afterload) diminishes.¹⁷ On the contrary, stenosis is poorly tolerated and may lead to pulmonary oedema.¹⁸ Cardiac contractility must be monitored since it is crucial in predicting the outcome of pregnancy.⁷

The cardiac conditions associated with m-WHO classes of risk III and IV are summarised in Table 1.⁹

Management of delivery

With a view to minimising the risk of the onset of heart failure, delivery beyond 40 weeks gestation is not recommended. The gold standard for delivery is week 37-to-38, but for mothers with complex and hypercomplex CHD, delivery can be brought forward. In these cases, prophylactic corticosteroids are needed to expedite foetal lung maturity and prevent respiratory distress syndrome.^8,19,20 Apart from rare exceptions, vaginal delivery should be preferred, as compared with Caesarean section, complications (haemorrhage, infection, haemodynamic disturbances, coagulation disorders) are less frequent.²¹ Caesarean section is limited to a few indications, such as patients who are still taking anticoagulants, in Marfan patients with aortic dilatation/dissection, severe aortic stenosis, and Eisenmenger syndrome.¹⁹ Epidural analgesia is preferred. ACHD women should be monitored closely for six weeks after delivery.¹⁹

Conclusions

Pregnancy can be a reality for most ACHD women, though not all, and it is not without risk. Pregnancy is always contraindicated in patients with pulmonary arterial hypertension, irrespective of its aetiology. However, patients with single ventricle and Fontan physiology can become pregnant and deliver successfully. Pre-pregnancy risk should be discussed in specialised centres, especially for patients in risk classes m-WHO III and IV. All pregnancies, particularly those at higher risk, should be managed in a tertiary care centre capable of providing the necessary assistance to both the mother and infant. The approach should be personalised. Follow-up during pregnancy and delivery should be provided in all cases. The desire for parenthood, which at times is extreme in ACHD women, may often be accomplished, thus providing a ray of hope in the lives of these patients.