Yoga and High Blood Pressure

(Hypertension)
By Arjun Von Caemmerer

Yoga teachers often experience students coming to class, sent by their doctor, to do yoga to help de-stress and help their high BP. High Blood
Pressure is a serious medical condition and cannot be treated casually by students or teachers of yoga. In this article Arjun Von Caemmerer, a general
practitioner of medicine and an Intermediate Junior Level 3 teacher, explains about High Blood Pressure in an endeavour to inform teachers, teacher
trainees and students of yoga about the complexities of the subject.

Definition:
Hypertension (HT) is persistent and abnormally raised
pressure of blood within the arteries (which convey
oxygenated blood from the heart to the tissues).
Normal blood pressure control is complex and involves
interactions between the nervous system, endocrine
glands (which release hormones), organs (heart, lungs,
kidneys) and tissues (muscles, skin).
Hypertension is NOT synonymous with stress, although
some people under stress do develop raised blood
pressure.

Why is it important?
Raised blood pressure is a risk factor for blood vessel
disease including strokes, heart disease, kidney
impairment, and some kinds of dementia.
It is more serious and significant if the person affected
also has other risk factors for blood vessel disease. These
include: Smoking, diabetes, obesity, family history of
blood vessel disease before age 60, high blood
cholesterol and increased age. It is more likely for these
groups to be on pharmacological treatment.

How Common is Hypertension?

Types:
Primary Hypertension (also known as idiopathic or
essential hypertension).
The cause is unknown. This accounts for the vast
majority (>90%) of hypertension in adults. It is likely is the
end result of many factors operating together (genetic,
lifestyle, and others as yet unidentified).

Secondary Hypertension
An underlying cause can be identified. This is rare, but
accounts for most hypertension in children and some in
adults. Causes include structural abnormalities of blood
vessels, hormone secreting tumours, side effects of
medication (eg. The contraceptive pill) or diet (eg excess
licorice ingestion).
In Ayurvedic terms high BP may reflect a pattern of dosa
imbalance:

Kapha: often associated with overweight, lethargy
and fluid retention.

Pitta: Often reflective of sympathetic nervous
system or surya nadi over stimulation with irritability
and impatience, redness of face and eyes...

Vata: often labile, rising in response to stress, an,
anxiety and fractured sleep; often reflective of
nervous system imbalance.

Estimates vary according to the population studied. In

Australia 30% of the population above 25 years have
hypertension.

How does raised blood pressure feel?

Most often having raised blood pressure will not produce
predictable symptoms. Many symptoms commonly
attributed to high blood pressure (eg headache, a feeling
of fullness in the head, lightheadedness) are not in fact
due to high BP.
High BP is usually discovered incidentally eg during a
health check.

How is it measured?
The most direct way of measuring pressure within the
arteries would be to have a pressure-sensitive probe put
inside the artery. This is done only in research settings as
it is invasive and impractical for everyday use.
A standardised technique for measurement is
recommended to reduce variability. A mercury
sphygmomanometer is used. Ideally no caffeine or
nicotine should have been consumed for ~2 hours prior
to measurement. A cuff is placed around the bare arm
(which is supported at heart-height) of the seated person.
This cuff is then inflated to around 30mm above the
disappearance of the pulse felt at the wrist. It is
important that the cuff not be too narrow, or a falsely

high reading is likely. The cuff is slowly deflated whilst the

transmitted sounds of the arterial pulsations are listened
for with a stethoscope over the brachial artery at the
elbow. The systolic pressure is defined when sound first
appears; the diastolic pressure at the point at which the
sound disappears. This is repeated for reliability, then
averaged and expressed as a ratio systolic/diastolic eg
120/80 [mm Hg, or millimetres of Mercury].
A single elevated reading is not sufficient for a diagnosis.
Traditionally, three or more readings on separate
occasions are required before the label of an individual as
hypertensive is appropriate.
White coat hypertension refers to high readings
induced by the stress of measurement. People who get
this are more likely to develop real hypertension in the
long run than those who dont. Nonetheless, if this is
suspected measurements done away from the clinic
setting - either by wearing a device for ~24 hours or by
doing a series of automated spot readings - can help to
clarify whether or not hypertension is truly present.

heart). These normally lower heart rate and may cause

fatigue and reduced exercise-tolerance.
3) Calcium-channel blockers: these relax the smooth
muscle within the blood vessel walls to reduce resistance
to blood flow. They can variably affect heart rate and may
cause facial flushing or ankle swelling.
4) ACE-inhibitors: these work on the kidney to partially
block the production of a hormone (angiotensin
converting enzyme) which in turn normally helps produce
the blood-pressure raising hormone, angiotensin. These
can cause an irritating dry cough.
5) Centrally acting: these work on the central nervous
system to reduce sympathetic tone in the peripheral
nervous system. They are not commonly used now, and
generally have more side-effects than the other
medications.
It is important to know that medications can impair
normal physiologic adaptations. For example, the
transient dizziness students may feel if they get up
quickly from Rope Adho Mukha Svanasana may be
intensified where blood pressure medication is being
used.

What is normal? What is abnormal?

Category
(pressure in mm Hg)
Optimal
Normal
High-Normal
Borderline
Mild HT
Moderate HT
Severe HT

Systolic

Diastolic

<120
<130
130-139
140-149
150-159
160-179
>180

<80
<85
85-89
90-94
95-99
100-109
>110

When is hypertension treated?

Whether or not high BP is simply monitored, treated with
lifestyle measures alone, or treated additionally with
medication depends upon the context. As a risk factor for
blood vessel disease it heightens in significance if other
risk factors are also present, if the elevation is severe, or
if there is already evidence of secondary damage (eg to
kidneys or heart).

How is high BP treated?

Treatment is individualised. Lifestyle modification may
include: weight reduction, regular physical activity,
dietary modification (a vegetarian diet is best), and
curtailment of salt, alcohol and nicotine use. Many
practitioners advise their patients to start yoga,
recognizing that there is a proven benefit from
meditative disciplines which combine physical activity
with relaxation.

Yoga students who are taking medication and have wellcontrolled hypertension still have hypertension. There is
a common misconception which equates using
medication for hypertension as somehow eradicating the
diagnosis. Abruptly stopping medication may result in a
sudden rebound increase in blood pressure. This can be
dangerous.
As Smt. Geeta Iyengar notes regarding hypertensive
students: do not disturb their psyche by asking them to
stop medication. Teach those asanas which help to bring
the pressure down. Let them build up confidence in
themselves. (Basic Guidelines for Teachers of Yoga)

Teaching Yoga and High Blood pressure

Appropriate yoga can definitely help reduce raised blood
pressure. But teaching therapeutic yoga for this purpose
requires a level of experience in teaching and a
committed, sensitive student. Irregular inconsistent yoga
targeted to high BP will likely only increase fluctuations in
BP. If a student decides to use yoga to help wean
themselves off medication, I would advise that the
process be done in liaison with that persons health
practitioner so that their BP can be monitored.

There are several types in common use:

In looking at the effects of asanas, remember that the

energetic effects are greater than the
hydrostatic/gravitational effect. Thus not all inversions
are contra-indicated as is commonly thought. In fact,
supported Halasana and Viparita Karani are both
positively recommended where BP is high.

1 ) Diuretics: these increase sodium (salt) excretion from

the kidneys
2) B-blockers: partially block the stimulant action of
sympathetic nervous system hormones (adrenalin and
noradrenalin) on their target tissues (blood vessels and

For the student attending classes and hoping to get

benefit from yoga, the appropriate avenue is to minimise
fear, maximise confidence and avoid harm. In general
terms, over stimulating and over-exertive asanas should
be avoided. This includes some standing poses (such as

How do medications work?

Virabhadrasana 1 & Surya Namaskar), Sirsasana, active

backbends, and any asana where the breath is being
restricted, or held in. Antara Kumbhaka (retention of
breath after inhalation) is to be avoided.
Of benefit are the simple sitting asanas, supported supine
asanas, supported forward bends, HalasanaSarvangasana, Setubhandha, Viparita Karani, lying Ujjayi
preparation, Ujjayi pranayama, Viloma 2 pranayama,
Savasana i.e. all those asanas which have a cooling
effect (or, as Dr Sulocha Telang puts it, stimulate chandra
nadi [the parasympathetic nervous system] and quieten
surya nadi [the sympathetic nervous system].
Some students habitually over-exert and this needs to be
monitored, especially in those asanas which might be of
theoretical benefit but in which beginner students may
struggle eg supported forward bends or Sarvangasana.
Geeta Iyengar in Yoga - A Gem for Women, recommends
this sequence for reducing high BP: Paschimottonasana,
Uttanasana, Adho Mukha Svanasana, Halasana,
Setubhandha Sarvangasana, Salamba Sarvangasana,
Adho Mukha Svanasana, Uttanasana and
Paschimottonasana.
It takes the student time and guidance to learn how to do
these asanas, even in their supported variations, without
struggle so that they can be beneficial.
References:
1. Basic Guidelines for Teachers of Yoga BKS Iyengar and
Geeta lyengar p.22
2.Yoga -A Gem for Women Geeta Iyengar ChX Hints and
Suggestions for the
Practice of Asanas
Further reading:
1 )Understanding Yoga Through Body Knowledge Dr
Sulocha Telang Ch VIII The Water Principle; ChX The Air
Principle
2)A Matter of Health Dr Krishna Raman Section 4
Cardiovascular Disorders
Arjun von Caemmerer is a general practitioner and a certified
Intermediate Junior Level 3 teacher. He is teaches in Hobart at
the Hobart Iyengar Yoga School, is a qualified teacher trainer and
assessor of the Association.



Yoga and Cardiovascular Disease

Arjun von Caemmerer (April 2013)

Cardiovascular disease includes high blood pressure (hypertension),

coronary artery disease (heart attack, angina) and stroke.

The incidence of all these conditions increases with increasing age.

Approximately 10% of Australian adults aged 35-44 have cardiovascular
disease, increasing to about 70% over the age of 85.

Approximately one in three Australian adults over the age of 25 have high
blood pressure (defined as 140/90, or on treatment). Untreated high blood
pressure is a major risk factor for heart disease and stroke. Although
elevated blood pressure does not usually cause any symptoms, the
medications commonly used to lower blood pressure may have significant
side effects.

Approximately 5% of adult males aged 35-44 have coronary artery disease.
Around 25% of women and 30% of men over the age of 85 have coronary
artery disease.
The main increase for men occurs in their 5th and 6th decades.
The main increase for women occurs in their 7th and 8th decades.

Coronary artery disease is commonly treated medically with a combination
of surgery (stent or bypass) and medications. Surgery aims to relieve
blockages to the hearts blood flow. A cardiac stent is a hollow tube placed
within a diseased heart blood vessel: it essentially provides a new channel

for blood flow to the heart. A bypass graft replaces the diseased blood vessels
with the persons own blood vessels (usually with their leg veins, but
occasionally with a chest wall artery).
To prevent further blockages, either within the stent or the grafted blood
vessels, some form of blood-thinning medication is commonly used.
Additional medicationsaimed at lowering both cholesterol and blood
pressure levels are often employed simultaneously.

Approximately 2% of adults have had a stroke by their 5th decade; this
increases to ~10-15% above the age of 75. It is common for those who have
had stroke to be on a similar range of medication as those used in coronary
artery disease (i.e. for blood pressure and cholesterol lowering and
occasionally also for blood thinning).

Implications for yoga teachers

1) High blood pressure
Students requiring blood pressure medication still have hypertension even if
their elevated blood pressure is well controlled.

Side effects from blood pressure medication commonly include:
*Light-headedness on changing body positions, especially if the change is
abrupt.
Examples are: standing abruptly, whether from a lying, seated (especially
squatting), or inverted position. The light-headedness may be a result of an
exaggeration of the usual blood pressure changes that accompany alterations
in body position (postural hypotension), and/or because the medication
may delay the ability of the body to maintain an adequate cardiac output.

This latter can occur, for example, with beta-blockers, which can prevent the
heart from appropriately increasing its rate in response to a fall in blood
pressure.

*Easy fatiguability this is especially common with beta-blockers (which can
prevent the heart from accelerating normally in response to increased
oxygen demand).

*Increased tendency to muscle cramp this is especially common where
diuretics (fluid tablets) are used to treat high blood pressure.

2) Coronary artery disease
Students with a cardiac stent or history of bypass surgery still have coronary
artery disease, even if symptom-free. New chest pain or unusual
breathlessness in such an individual may be a serious warning sign, and
requires prompt and professional assessment.

It can take several months for the split sternum to heal soundly following
cardiac bypass surgery, and some asanas (for example backbends, even if
passive) may be quite painful for this period.

3) Blood-thinning medication
Most commonly used is aspirin. Other blood-thinning medication (such as
clopidogrel and warfarin) may additionally be used, especially in cases of
recurrent strokes, irregular heart rhythms, and in students with a cardiac
stent.
These medications can lead to easy bruising and care is needed with props
that pressurize the skin directly (belts, hard blocks, chair-seat edges). Blood-

thinning medication can also contribute to dramatic nosebleed, and it is

useful to remember the basic first-aid management of this (elevation of the
head, steady pressure, and application of a cool pack).

4) Irregular heart rhythms
The most commonly treated abnormal heart rhythm is atrial fibrillation
(AF) where the upper heart chambers (the atria) contract in an
uncoordinated, rapidand ineffectivemanner. As this arrhythmia reduces
cardiac efficiency by around 25%, easy fatiguability and exaggerated
postural blood pressure changes are common. Fatigue can be further
aggravated by the medication (beta-blockers and digoxin) that is commonly
used to dampen down the over-rapid heart rate.
To prevent a clot forming in the essentially static fibrillating chamber (and so
reduce the risk of secondary stroke), AF is also generally treated with
powerful blood thinning medication.

It seems sensible to recommend all certified Iyengar yoga teachers ensure
that they regularly maintain their basic cardiopulmonary resuscitation skills.

Commonly used cardiovascular medications: a summary

Medication

Mechanism

of Use

Side

Caution

action

Effects

Beta

Partially block the After heart

Fatigue

Exertion

blockers

action of

attack

(E.g.

adrenalin,

Postural

standing

Examples:

especially on the

After cardiac dizziness

postures;

metoprolol,

heart, preventing

surgery

surya

atenolol

it accelerating in

namaskar;

response to

High blood

active

exercise

pressure

backbends)

(but reduce the

Cardiac

Abrupt

risk of sudden

arrhythmia

changes in

cardiac death)

body
position

Diuretics

Increase renal salt High blood

Postural

As above

excretion

dizziness

Examples:

indapamide,

Fatigue

frusemide

Muscle

pressure

cramps

Medication

Mechanism

of Use

action

Side

Caution

Effects

Blood

Inhibit platelet

After heart

Easy

Direct

thinners

action

attack and

bruising

pressure on

(aspirin;

after stent

the skin

Examples:

clopidogrel;

surgery

with hard

aspirin,

dipyrimadole)

props

clopidogrel,

Cardiac

dipyrimadole; Inhibit clotting

arrhythmias

factors (warfarin)

warfarin

Prevention

of stroke

Nosebleed

Digoxin

Slows heart rate

Arrhythmia

and increases

heart beat

Heart failure

Nausea

Backbends

strength
ACE

Reduce blood

High blood

Postural

Abrupt

Inhibitors

pressure (inhibit

pressure

dizziness

changes in

kidney-based

body

Angiotensin

Heart failure

position

Converting
Enzyme)

Reduce heart
strain