DOI 10.

1515/hmbci-2013-0056Horm Mol Biol Clin Invest 2014; 18(3): 137143

Marcia Kiyomi Koike* and Roberto Cardoso

Meditation can produce beneficial effects to

prevent cardiovascular disease
Abstract: Coronary heart disease is the major cause of
global cardiovascular mortality and morbidity. Lifestyle
behaviour contributes as a risk factor: unhealthy diet,
sedentary lifestyle, tobacco, alcohol, hypertension, diabetes, dyslipidemia and psychosocial stress. Atherosclerosis
pathologic mechanisms involving oxidative stress, dyslipidemia, inflammation and senescence are associated with
arterial wall damage and plaque formation. Stress reduction was observed in several types of meditation. After
meditation, hormonal orchestration modulates effects in
the central nervous system and in the body. All types of
meditation are associated with blood pressure control,
enhancement in insulin resistance, reduction of lipid peroxidation and cellular senescence, independent of type
of meditation. This review presents scientific evidence to
explain how meditation can produce beneficial effects on
the cardiovascular system, and particularly regarding vascular aspects.
Keywords: atherosclerosis;
meditation.

cardiovascular

disease;

*Corresponding author: Marcia Kiyomi Koike, IAMSPE, Programa de

Ps-Graduao em Cincias da Sade, Av Ibirapuera, 981, 2 andar,
So Paulo, Brazil, 04029000, Phone: +55 11 9 99648421,
Fax: +55 11 30617170, E-mail: mkoike2011@gmail.com
Marcia Kiyomi Koike: Programa de Ps-graduao em Cincias da
Sade, Instituto de Assistncia Mdica do Servidor Publico Estadual
(IAMSPE), So Paulo, Brazil; and LIM-51, Departamento de Clinica
Mdica, Faculdade de Medicina, Universidade de So Paulo (USP),
So Paulo, Brazil
Roberto Cardoso: Ncleo de Medicina e Prticas Integrativas
(NUMEPI), Universidade Federal de So Paulo (UNIFESP), So Paulo,
Brazil

Introduction
Currently, the main causes of cardiovascular disease
mortality and morbidly are coronary heart disease (CHD)
and stroke. It is well known that CHD is associated with a
western lifestyle, including tobacco use, unhealthy diet,
irregular physical activity, abnormal lipid profile, hypertension, abdominal obesity, alcohol intake, diabetes,

and psychosocial stress [1]. Among possible strategies to

manage physical and psychological stress, meditation
has been proposed as an efficient and easy applicable
procedure.
Meditation is an ancient technique to promote modified state of consciousness and physical relaxation. Actually, the prevalent operational definition of meditation was
proposed by Cardoso and collaborators [2]. They consider
the procedure to be meditation when it has the following five operational parameters: (1) a specific technique
clearly defined; (2) muscle relaxation somewhere during
the process; (3) logic relaxation; (4) a self-induced state;
and, (5) use of self-focus skill, termed anchor.
A meditation technique can be classified using
active (cathartic or movement), passive (concentrative
or perceptive) or mixing techniques. Passive concentrative meditations are the most well-studied in medicine,
and include transcendental meditation, Zazen, Zen and,
Vipassana. These meditations have a specific anchor
that permits total mental routing to a single focus, avoiding involvement with thought sequences and, getting
logic relaxation [3]. Other meditations studied are
Mindfulness, Love Kind Meditation, Raja Yoga, and
QiGONG meditation.
In 1971, Wallace, Benson & Wilson identified the
wakeful hypometabolic physiologic state as the physiological condition resulting from meditation practice and
characterised by the reduction of heart rate, respiratory
frequency, oxygen consumption, carbon dioxide elimination and, an increase in electrodermic resistance and
amplification of alpha wave intensity [4]. The wakeful
hypometabolic physiologic state differs from the sleeping
state [5] and it was similarly observed in different types of
meditation technique [6].
Over the past four decades, physiological effects
during and after long-term meditation have been demonstrated. Meditation can cause detectable effects in:
1. Central nervous system: a) activation of prefrontal
cortex [7], cingulated gyrus [8], limbic system [7]
and, corpus callosum [7, 8]; b) increase of secretion
of inhibitory hypothalamic factors (somatostatin and
dopamine) [9]; c) reduction of secretion of stimulatory
factors (thyrotropin release hormone, growth hormone
release factor, corticotrophin releasing hormone)

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138Koike and Cardoso: Meditation and the cardiovascular system

[9]; d) Increase of secretion of beta endorphin [10],
serotonin [11] and, metalonin [12].
2. Autonomic nervous system: a) increase in heart
rate variability [13], indicating activation of the
parasympathetic system and reduction of activity of the
sympathetic system; b) reduction of norepinephrine,
epinephrine [14] and cortisol levels [15].
3. Heart and vessels: a) reduction of arterial pressure by
increasing nitric oxide [16] and, b) reduction of beta
adrenergic sensibility [17]; c) reduction of vascular
peripheral resistance [18]; d) reduction of aldosterone
level [11]; e) reduction of lipid peroxidation levels [16];
and, f) inflammatory response [19].
We conducted this review because of the elevated incidence of cardiovascular disease and to possible further
action to minimise them by meditation. This review presents recent evidence to explain beneficial effects of
meditation that could prevent primordial, primary and
secondarily cardiovascular disease. The review includes
articles published in the last 10 years, obtained from the
Medline electronic database using a combination of the
following descriptors: meditation, cardiovascular disease,
and atherosclerosis; and by sensitive and comprehensive
searches and lateral searching including checking citations. Articles published before 2003 were considered
only when related primarily to meditation. For clinical
studies, we considered meditation-only techniques in
agreement to operational definition [2] cited above and
with well-established protocol.

Body of the review

Stress is one of the most important contemporary events
in global health. Cardiovascular damage is one of the
main consequences. It is well known that regulation of
stress response and reduction of risk factors of specific
stress-decreasing approaches can be used in primordial
prevention of illness and prevention of new events in cardiovascular disease. Thus, it seems clear that meditation
can play an important role in this scenario, as it can be
used as an approach to reduce stress hormonal response,
blood pressure, insulin resistance, oxidative stress and
to improve the balance of the autonomic nervous system
and the immune system. In general, the biochemical
changes found in meditators were the opposite to those
found among chronically stressed individuals, such as
better mood state, improvement of adrenal and renal
functions [11].

The cardiovascular effects after meditation, such

as reduction of arterial pressure and pulse, were firstly
demonstrated in long-term meditators in a meditation in
groups for 10days by Dwivedi etal. in 1978 [20]. After the
1970s, other studies confirmed cardiovascular, respiratory, neuroendocrine and central nervous system modifications produced by meditation.
In normal individuals, short-term meditation practice
(5 days) has effects on neuroendocrine stress response,
reducing cortisol levels [21]. As demonstrated by Walton
and collaborators, transcendental long-term meditators
(8.5 years) showed improvements in mood, adrenocortical activity and kidney function, with lower cortisol and
aldosterone in serum, lower excretion of norepinephrine
metabolite, higher dehydroepiandrosterone sulphate and
serotonin metabolite [11]. Meditation may improve sleep
quality because of psychological modifications [22] and
increased melatonin releasing [12].
Gupta and collaborators showed improvement with
healthy and happy lifestyle programmes (Mount Abu
Open Heart Trial), based on principles of Raja Yoga,
consisted of meditation, a vegetarian diet and, moderate aerobic exercise. All patients had CHD with angiographically documented stable coronary disease, >50%
of stenosis in at least one major epicardial artery, were
included, and all participated in the 6.48-year follow-up.
The authors found important health improvements (cardiovascular, metabolic and psychologic aspects), and a
reduction in coronary stenosis and cardiac events. Adherence to the programme was an important aspect to benefit
these patients [23].
Thus, cardiovascular disease patients may benefit
from meditation. In a cohort study of 7.6 years, long-term
effects of Transcendental meditation showed a decrease
of 23% in primary outcome (all-cause mortality), a
decrease of 30% in rate of cardiovascular mortality and a
49% decrease in rate of cancer mortality in hypertensive
patients. In this study, Schneider and collaborators did
not investigate the possible mechanisms involved [24].
Similarly, in another study using Transcendental meditation, the practice of meditation was effective to reduce
the risk of mortality, myocardial infarction or stroke in
CHD African American patients [25]. As demonstrated by
Paul-Labrador and collaborators, a short-term protocol
(16 weeks) promoted the reduction of systolic blood pressure, reduction of insulin resistance and increasing in
heart rate variability by modulation of physiologic stress
response [26].
Meditation may also balance the lipid profile. In
a QiGONG meditation protocol, Lee and collaborators
observed a reduction of blood pressure, total cholesterol

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Koike and Cardoso: Meditation and the cardiovascular system139

and elevation of high-density lipoprotein after 8 weeks of

meditation [27]. Vyas and collaborators showed that Raja
Yoga meditation, as behavioural intervention, is effective
to reduce lipid profile (total and low-density lipoprotein)
in pre- and post-menopausal women, with short-term
(6months to 5 years) or long-term (>5 years) meditation
[28]. In another study, Zen meditation was effective to
modulate cardiovascular risk factors, reducing lipid peroxidation caused by oxidative stress. The lipid peroxidation was estimated by tiobarbituric acid reactivity and
higher nitric oxide level was estimated by measuring of
nitrite and nitrate [16].
It is well known that altered lipid profile is a factor
implied in vascular bed lesion. Other factors are oxidative
stress and shear stress that contribute in the first event
to the development of atherosclerotic plaques. Vascular bed is affected early in the structure and function in
normal individuals whose parents had premature myocardial infarction: carotid media-intimae thickness is more
pronounced and arterial reactivity is impaired [29]. In
Transcendental meditation, reduced systolic arterial pressure was associated with reduction of peripheral resistance [18]. Moreover, vascular cell senescence has been
appointed as important aspect to plaque formation.
We agree that developing a translational study on in
this theme would be unattainable. However, we selected
interesting experimental articles for this review as presented below.
The mobilisation of endothelial progenitor cells
is associated with haematopoietic stem cells of bone
marrow. In 2004, Landmesser and collaborators investigated statin treatment in endothelial nitric oxide synthase (eNO) knockout mice after myocardial infarction.
They observed that eNO biodisponibility is mainly a
mechanism to endothelial progenitor cells mobilisation,
myocardial revascularisation, ventricular function, interstitial fibrosis and survival [30]. In humans, the migration
capacity of endothelial progenitor cells was impaired in
CHD patients, associated with ventricular dysfunction
and worst ventricular remodelling [31, 32] and white
blood cells (WBC) senescence [33]. In the last 10 years,
shortening of WBC telomere length has been considered
to be an ageing marker for conditions related to stress or
chronic diseases. Telomeres are DNA sequences located at
the ends of chromosomes to protect them during cellular
replication. Telomere length shortens with chronological
age and is shortened in people with age-related diseases
such as work-related exhaustion [34], bad sleep quality
in women [35], mood disorders [36], obesity [37], insulin
resistance and diabetes [38, 39], osteoarthritis [40], osteoporosis [41], stroke [42], hypertension [43] and CHD [44].

An acceleration of telomere shortening in response to life

stress is negatively associated with perceived stress [45].
Thus, the telomere length informs us about the biological age of an individual, and that it does not always correspond to chronological age.
Differences between biological and chronological
ageing may contribute to elevating the risk of cardiovascular disease and cellular senescence that participate in
endothelial dysfunction and atherosclerosis. Chronologic ageing and cardiovascular risk factors are inversely
related to WBC telomere length [43]. The WBC telomere
length is related to a 3-fold increase in the risk of myocardial infarction occurrence [46, 47] and bone marrow dysfunction [33].
The shortening of WBC telomere length is related to
the shortening of telomere length in vascular tissue. Coronary endothelial cells of CHD patients, in areas of atherosclerotic lesion, have shortened telomere length when
compared to areas without lesions or patients without
CHD [48]. A larger study conducted with offspring of
Framingham patients showed that the shortened WBC
telomere length was associated with the increase of
carotid intimae-media thickness, mainly in obese men
[49]. In addition, the shortening of WBC telomere length
was observed in hypertensive patients [50] and in CHD
patients [42], and it was associated to reduction of highdensity lipoprotein and increase of oxidative stress in diabetic CHD patients [38].
Experimental and clinical investigations indicate that
stress-induced vascular senescence can be prevented by a
telomere stabilising approach, such as physical exercise
[51]. In the same way that physical exercise has shown
a buffering effect on the senescence of immune system
and vascular cells [52], meditation has shown effects on
telomere length. The first study evaluating meditation
(Buddhist) and telomere was conducted by Jacobs and
collaborators in 2011 [53]. They demonstrated that intensive meditation training increased perceived psychological stress control and reduced neuroticism. These aspects
implied in higher telomerase activity cellular enzyme
responsible to telomere length and maintenance in
WBC. Recently, Loving Kindness Meditation was associated to longer WBC telomere length in women [54]. On the
one hand, this field still deserves to be explored further,
as there is a lack of cohort studies to evaluate the role of
meditation in the prevention of cardiovascular disease
and to explain the mechanisms involved in this. On the
other hand, molecular mechanisms begin to be elucidated. In higher states of consciousness of two long-term
meditators (23 and 16years of meditation), the response
to stress was reduced and the genome-wide expression

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140Koike and Cardoso: Meditation and the cardiovascular system

showed general down regulation of metabolic and cell
cycle processes, signalling, protein transport, regulation
of gene expression, DNA repair, epigenetic mechanisms
[55]. In healthy individuals, brief daily Yogic meditation
modified the transcriptome related to immune system
activity, reducing transcriptional via in expression of proinflammatory cytokines and innate antiviral response [56].
Bhasin and collaborators, applying a Kirtan Kriya meditation and other relaxation response approach among
healthy long-term practitioners and even in novices (8
weeks), observed that relaxation response is the counterpart of the stress response by enhanced expression of
genes associated with energy metabolism, mitochondrial
ATP synthase, insulin secretion and telomere maintenance, and reduced expression of genes linked to inflammatory response and stress-related pathways [57].
Another unexplored field is how meditation could
affect the neuroendocrine balance in obese patients.
Ghrelin is an endogenous peptide related to appetite
and feeding. Ghrelin may induce weight gain not only by
stimulating appetite but also by decreasing fat utilisation
[58]. In experimental obesity, ghrelin level is elevated and
is associated to anxiety-like behaviours. Short or longterm exercise training result in reduction of hypothalamic
ghrelin in rats [59] and in humans [60]. Intravenous injection of synthetic ghrelin increased ACTH and cortisol
level [61, 62] in volunteers, indicating an association of
this peptide with stress conditions. The ghrelin level after
exercise in humans is elevated when there is a reduction
of body weight is present. Therefore, the ghrelin modulation on stress by exercise training and by meditation
should be more carefully investigated.
Despite these evidences, the use of meditation practice as an approach to complementary treatment of cardiovascular conditions is not as common as one would
expect [63].

Expert opinion
In 2005, The National Center for Complementary and
Alternative Medicine (NCCAM) of National Institutes of
Health (NIH), recognised meditation as an acceptable
approach in the field of health. On that occasion, possible
conditions to apply meditation as a therapeutic indication
were presented: anxiety, pain, depression, stress, insomnia, cardiovascular disease, aids and cancer. Moreover,
it was applied for mood and self-esteem, and wellness. In
our opinion, considering the data presented in this review,

meditation can be a strategy to complement clinical treatment. The beneficial effects of meditation are beyond
physical effects. Cognitive, memory, and mood alterations
associated to reduced neuroticism can change behaviour
and, consequently, improve lifestyle.

Outlook
The World Health Organization has been focusing on
improving the quality of life to promote health in general.
Likewise, meditation can be a good way for those who
adopt a western lifestyle to produce several benefits in
their lives, including the reduction of cardiovascular
damage. Cellular and molecular aspects must be investigated to elucidate the mechanism of how meditations
act. In front of these evidences, genomic, transcriptomic,
proteomic, metabolomic investigations are useful. The
telomere lengths as predictor of future CHD could be
considered.

Highlights
Here we summarise the effects of meditation on
physiology that could represent possible protector
events to cardiovascular system. Meditation
can:modulate the neuroendocrine axis, reduce stress,
lower releases of cortisol and adrenaline;
regulate the autonomic nervous system and generate
reduction in blood pressure and cardiac frequency;
reduce mortality and the risk of myocardial infarction
and stroke by reducing resistance to insulin, lipid
perodixation, and increase HDL;
optimise biological age by acting on senescence
mechanisms: increasing telomerase activity and
preventing the shortening of telomeres of circulatory
leukocytes or endothelial cells.
In conclusion, among several other effects, meditation
protects the neuroendocrine axis, vascular damage and
senescence. Thus, for all the evidence presented, we are
inclined to believe that the meditation practice may be
clinically useful in primordial prevention of atherosclerosis and the secondary prevention of myocardial infarction
and stroke.
Received September 30, 2013; accepted April 17, 2014

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Koike and Cardoso: Meditation and the cardiovascular system141

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