Meta-Analysis of Effects of Voluntary Slow Breathing

Exercises for Control of Heart Rate and Blood Pressure in

Patients With Cardiovascular Diseases
Yan Zou, MNa,b, Xin Zhao, PhDa, Yun-Ying Hou, MNb, Ting Liu, MNb, Qing Wu, MNb,
Yu-Hui Huang, PhDc,**, and Xiao-Hua Wang, PhDa,*

Rising heart rate (HR) and elevated blood pressure (BP) cause a greater frequency of
cardiovascular events. Many patients cannot maintain target HR and BP using pharma-
cological therapies. To evaluate the effectiveness of voluntary slow breathing exercises in
reducing resting HR and BP, we searched Embase (1974 to April 2016), PubMed (1966 to
April 2016), the Cochrane Central Register of Controlled Trials (issue 4, April 2016), and
PEDro (www.pedro.org.au; 1999 to April 2016). The primary outcome was the mean change
in HR at rest. Secondary outcomes included changes in systolic blood pressure (SBP) and
diastolic blood pressure (DBP) as well as compliance with the breathing training. Finally,
we included 6 studies consisting of 269 subjects. Practice of the breathing exercises resulted
in statistically significant HR reduction (mean difference: L1.72 beats/min, 95% CI L2.70
to L0.75). Reductions were seen in SBP (mean difference: L6.36 mm Hg, 95% CI L10.32
to L2.39) and DBP (mean difference: L6.39 mm Hg, 95% CI L7.30 to L5.49) compared
with the controls. Trial durations ranged from 2 weeks to 6 months. In conclusion,
the existing evidence from randomized controlled trails demonstrates that short-term
voluntary slow breathing exercises can reduce resting HR, SBP, and DBP for patients
with cardiovascular diseases. Ó 2017 Elsevier Inc. All rights reserved. (Am J Cardiol
2017;120:148e153)

Voluntary slow breathing exercises (VSBEs) are defined Methods

based on a self-controlled breathing rate to achieve
Studies were eligible if they met the following standards:
decreased respiratory rate and increased respiratory ampli-
(1) studied cardiovascular disease mainly including coro-
tude (tidal volume).1 It is an easy-operated/practical method
nary heart disease, hypertension, and heart failure; (2) pa-
for patients with cardiovascular disease. However, its effects
tients were aged over 18 years; (3) HR and (or) BP was an
on reductions in heart rate (HR) and blood pressure (BP) are
outcome; (4) the language of the studies was English; and
still controversial. Silva et al.2 found that there was no
(5) were randomized controlled trails (RCTs) with designs
significant reduction in HR or systolic blood pressure (SBP)
involving VSBE and natural breathing as the intervention
after deep breathing exercises for patients with coronary
and control arms, respectively. Exclusion criteria were: (1)
artery disease, hypertension, and diabetes mellitus. Mean-
abstracts, review studies, case reports, or editorials; (2)
while, a study by Dixhoorn et al3 revealed that slow
repeated reports or low-quality studies; (3) studies not
breathing was related to beneficial effects on resting HR for
providing enough needed data or data were unobtainable
myocardial infarction patients. Another recent study also
from original investigators; (4) subjects with other serious
demonstrated that slow breathing training produced a
diseases or complications; (5) device-guided breathing ex-
valuable reduction in resting HR and SBP in hypertensive
ercises; and (6) only 1 intervention.
patients.4 Thus, we performed a meta-analysis to analyze the
Embase (1974 to April 2016), PubMed (1966 to April
impact of VSBE on HR and BP for patients with cardio-
2016), the Cochrane Central Register of Controlled Trials
vascular disease.
(issue 4, April 2016), and PEDro (www.pedro.org.au; 1999
to April 2016) were searched to obtain studies meeting the
a
Division of Cardiology, The First Affiliated Hospital of Soochow eligibility criteria. Terms used included “breathing exercise/
University, Suzhou, China; bSchool of Nursing, Soochow University, slow breathing” and “heart rate/blood pressure.” We also
Suzhou, China; and cCyrus Tang Hematology Center, Soochow University, searched the citations of full-text studies retrieved. Two
Suzhou, China. Manuscript received February 1, 2017; revised manuscript reviewers screened studies through the titles and abstracts
received and accepted March 28, 2017. independently to confirm whether the study met the inclu-
Drs. Zou and Zhao are considered as first authors of this work. sion criteria. Data extracted independently by 2 investigators
See page 153 for disclosure information. included study characteristics and intervention information.
*Corresponding author: Tel: (86) 512-65221447; fax: (86) 512-
Disagreements were resolved in consultation with an arbi-
65125097.
**Corresponding author: Tel: (86) 512-65880877-3507; fax: (86) 512-
trator. We contacted the investigators of original studies for
65880929. missing information when necessary.
E-mail address: hyhui20126@163.com (Y.-H. Huang) or Primary outcomes included the mean change in resting
sxwang2001@163.com (X.-H. Wang). HR. Secondary outcomes included changes in SBP and

0002-9149/17/$ - see front matter Ó 2017 Elsevier Inc. All rights reserved. www.ajconline.org
http://dx.doi.org/10.1016/j.amjcard.2017.03.247

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 Miscellaneous/Slow Breathing Exercise and Meta-Analysis 149

Table 1
Methodological quality of included studies
1 2 3 4 5 6 7 8 9 10 11 Score Level

Dixhoorn 1998 þ þ - - þ - - - þ þ þ 5 2
Silva 2014 þ þ - þ - - - þ - þ þ 5 2
Jones 2015 þ þ þ þ - - - þ þ þ þ 7 1
Modesti 2010 þ þ - þ þ þ - þ þ þ þ 8 1
Mourya 2009 þ þ þ þ - - þ þ þ þ þ 8 1
Sundaram 2012 þ þ þ - - - þ þ þ þ þ 7 1

1 ¼ eligibility criteria specified; 2 ¼ subjects randomly allocated to groups; 3 ¼ concealed allocation; 4 ¼ group similarity at baseline; 5 ¼ blinding of
subjects; 6 ¼ blinding of therapists; 7 ¼ blinding of assessors; 8 ¼ outcome measures obtained from more than 85% of subjects; 9 ¼ intention-to-treat analysis;
10 ¼ reporting of between-group statistical comparison results; 11 ¼ point measures and measures of variability reported; þ ¼ present; - ¼ no information
available or not done.

Figure 1. Flow chart of search results.

diastolic blood pressure (DBP) as well as compliance with
the intervention. When data were shown only in graphical
form, we extracted information from the figures using the
Getdata Graph Digitizer, version 2.25 (http://getdata-graph-
digitizer.com/). When the trial provided only the mean
and SD before and after the intervention in each
group and those change between baseline and final
measurement were missing, the SD of the change could be
transformedq byffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
the formula in the Cochrane Handbook 4.2.2
(SDðCÞ ¼ SDðBÞ2 þ SDðFÞ2 2  R SDðBÞ  SDðFÞ;
C, change value; B, baseline value; F, final value).5 The
R values for HR, SBP, and DBP were 0.75, 0.76, and 0.76
in the experimental group and 0.93, 0.8, and 0.54 in the
control group, respectively.6 Because the R value was
estimated using data from other studies, we chose sensitivity
analysis to test the stability of the result.
We used the Physiotherapy Evidence Database scale7 to
evaluate the methodological quality of each included study.
For assessing bias, the tool involves 11 items7 (Table 1).
The total scale score is 10. The second item to the eleventh
item each count as a point. Item 1, used to evaluate the
ffi external reality, is not accounted for in the total score.
Scores of 9 to 10 represent the best quality, scores of 6 to 8
represent good quality, scores of 4 to 5 represent general
quality, and scores < 4 represent poor quality.8
The meta-analysis was performed using Review Manager
5.3 software. We used it to calculate the mean difference

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150 The American Journal of Cardiology (www.ajconline.org)

Table 2
Clinical characteristics of the patient populations from included studies at baseline
Study Population Number Age (MSD) years Sex (men/women)

C I C I C I

Dixhoorn 1998 Post-myocardial infarction, Netherlands 39(51.3%) 37(48.7%) _ _ 74/2

Silva 2014 Myocardial arterial disease (14 diabetes mellitus),India 20(50%) 20(50%) 50-59(47.5%) 30/10
Jones 2015 Hypertension, Thailand 10(50%) 10(50%) 50.45.4 53.44.3 _ _
Modesti 2010 Hypertension, Italy 24(45.3%) 29(54.7%) 58 (53-61)* 58(54-62)* 16/10 16/13
Mourya 2009 Stage 1 essential hypertension, India 20(50%) 20(50%) 20-60 12/8 10/10
Sundaram 2012 Essential hypertension, India 20(50%) 20(50%) 52.14.58 53.05.4 12/8 14/6

C¼ control group; I¼ intervention group; e ¼ no information available.

* The data are represented by the mean (95% CI).

Table 3
Interventions of included studies
Study Duration Intervention Comparison Outcome

Dixhoorn 1998 3 months Exercise rehabilitation þ breathing relaxation Exercise rehabilitation Change in HR, respiration rate, and respiratory
sinus arrhythmia
Silva 2014 0.5 month Perform deep breathing exercises twice a day for Breathing naturally Change in HR, SBP, DBP, anxiety and
10 min. depression
Jones 2015 2 months Breathing with a duty cycle (IT:TRT) of 0.4 with Normal daily living Change in HR, SBP, DBP and heart rate
TRT of 10 s; resting for 5 s after every 6 variability
breaths; performing at home for 30 min, 2
times/day
Modesti 2010 6 months 4-6 beats/min, performing ‘abdominal’ breathing Reading books Change in office, mean-24 h, daytime and night-
with a 1:2 inspiration: expiration ratio for 20 time SBP, DBP and HR. Change in QoL
min every day.
Mourya 2009 3 months Right and left nasal breathing alternately for Breathing naturally Change in SBP and DBP, S/L ratio, 30:15 ratio,
15 min, approx. 5-6 beats/min twice daily; Valsalva ratio, E/I ratio, handgrip test, cold
each nasal breath for 6 s. pressor response to SBP and DBP.
Sundaram 2012 1 month Two times/week slow breathing exercises Breathing naturally Change in HR, SBP, DBP and respiratory rate,
Change in 6 Minute Walk Distance

30:15 ratio ¼ immediate heart rate response to standing; E/I ratio ¼ heart rate variation with respiration; IT ¼ inspiration time; QoL ¼ quality of life;
S/L ratio ¼ standing-to-lying ratio; TRT ¼ total respiratory time.

and 95% CI. Heterogeneity was evaluated by testing the
clinical characteristics of the enrolled studies as well as by
formal statistical testing using chi-square and I2 tests. Where
no heterogeneity was present, we performed a fixed-effect
meta-analysis. If substantial heterogeneity (I2>50%) was
detected, we sought the direction of effect, and where
applicable, used a random-effects analysis.
Results
Our initial search revealed a total of 2,549 records.
Screening progress was shown in Figure 1. Six RCTs were
ultimately included; characteristics of patient populations
from included studies are presented in Tables 2 and 3. Study
with a low risk of bias was defined as a study fulfilling 6 or
more of the 11 criteria, whereas a study meeting < 6 of the
criteria had a high risk of bias. The scores of the 6 RCTs for
risk of bias ranged from 5 to 8 (Table 1), indicating a low
risk of bias.
HR results of 229 patients were reported on 5 studies
included.2e4,9,10 Overall, VSBE resulted in an HR decrease
of 1.72 beats/min (95% CI 2.7 to 0.75, p ¼ 0.0005) with
low heterogeneity (I2 ¼ 13%; Figure 2, 1.1.1). According to
the Nfs0.05 ¼ (SZ/1.64)2S (Z representing the Z value of
each single study; S representing the number of all enrolled
studies) to calculate a fail-safe number (Nfs0.05),11 the Nfs0.05
was 182. That is, that another 182 negative studies would be
needed to reverse this result, thus indicating that the result is
stable.
Five studies including data from 193 patients showed the
effect of VSBE on BP.2,4,9,10,12 SBP was reduced by
6.36 mm Hg (95% CI 10.32 to 2.39; p ¼ 0.002) with
significant heterogeneity (I2 ¼ 80%; Figure 3, 2.1.1). By
reviewing the studies, we conducted a subgroup meta-
analysis after excluding a study by Mourya et al. The
result revealed that the heterogeneity (I2 ¼ 29%; Figure 3,
2.1.2) and SBP (mean difference: 4.63 mm Hg, 95%
CI 7.47 to 1.79) were significantly reduced. The Nfs0.05
for SBP was 23, which indicated that the result was stable.
DBP was reduced by 6.39 mm Hg (95% CI 7.30 to 5.49;
p <0.00001), and the heterogeneity was moderate (42%;
Figure 4, 3.1.1). The Nfs0.05 regarding DBP was 183, which
indicated that the result was stable.
Data on compliance with VSBE were reported on 3 studies.
In the study by Dixhoorn3 and Mourya,12 79% and 90%
compliance rates were reported, respectively. In the study by
Modesti et al,9 patients performed exercises 5.1 times/week (of
the 7 requested), for 22 min/day (of 30 minutes) on average.9

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 Miscellaneous/Slow Breathing Exercise and Meta-Analysis
Figure 2. VSBE versus control: effect on HR.
There were 3 studies3,4,12 that did not include the original
data we needed. After contacting the investigators, an
investigator4 provided the relevant results. Therefore, we
used the formula to calculate the SD of mean change. We
performed sensitivity analysis, excluding 2 studies3,4 from
the HR comparison and another 2 studies4,12 from the BP
comparison. The results indicated there were still significant
effects on improving resting HR, SBP, and DBP (Figure 2,
1.1.2; Figure 3, 2.1.3; and Figure 4, 3.1.2).
Discussion
Based on the inclusion and exclusion standards, we
selected all RCTs published in English to explore the effect
of VSBE on resting HR and BP. To avoid missing the
studies of the effects of VSBE on HR and BP, we did not
include “diseases of participants” in the search strategy.
Ultimately, the diseases of the participants in the included
studies were hypertension and coronary artery disease.
Many experimental and clinical observations have shown
that ischemic heart disease and heart failure can reduce
baroreflex sensitivity, which leads to sympathetic over-
activity and suppression of parasympathetic activity.13 The
origin of hypertension is characterized by such a charac-
teristic of autonomic imbalance.14 A low breathing rate
through activating the Hering-Breuer reflex could improve
baroreflex sensitivity,14 improve cardiac vagal tone, and
modulate sympathetic overactivity, thereby decreasing
resting HR and BP.15 Changes of autonomic imbalance and
baroreflex sensitivity promptly vanish after the restoration of
a normal breathing rate.16 However, recently a randomized
study17 has demonstrated that VSBE can induce chronic
autonomic changes in the modulation of baroreflex sensi-
tivity, ambulatory BP, renal resistive index, and HR
variability.
Resting HR reduction was closely related to the
decreased risk of cardiovascular events and all-cause
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151
death for patients with coronary heart disease and hy-
pertension.18,19 The risk of cardiovascular death or hos-
pital admission increased by 3% with every beat increase
from baseline HR and 16% with every 5 beats/min in-
crease in patients with heart failure.20 When resting HR
increased by 5 beats/min in patients with coronary heart
disease and left ventricular dysfunction, risks increased
by 8% for cardiovascular death, 7% for myocardial
infarction, and 16% for admission for heart failure.21
In addition, data from 4,065 patients suggested that for
each beat of HR change, there was a 1% change in
mortality risk for hypertensive patients.19 Our meta-
analysis showed that the practice of VSBE had the
overall effect of reducing resting HR by an average of 1.7
beats/min. Therefore, VSBE is a useful intervention to
reduce the resting HR of patients with cardiovascular
diseases.
Uncontrolled hypertension could lead to a higher risk of
heart failure, coronary heart disease, and major cardiovas-
cular disease events.22 With every 3.6 mm Hg reduction of
mean BP, the relative risks of total cardiovascular events,
strokes, coronary events, cardiovascular deaths, and total
deaths were 0.86, 0.72, 0.91, 0.75, and 0.78 times, respec-
tively, that of a 2.4 mm Hg reduction. These findings
indicated that reduction of BP is important for cardiovas-
cular patients. In our results, the practice of VSBE could
reduce SBP by 6.36 mm Hg and DBP by 6.39 mm Hg on
average. Therefore, VSBE could provide beneficial effects
of BP reduction for patients with hypertension and coronary
heart disease.
Only one study tested the effect of HR and BP at
6 months among the 6 included studies. Three3,9,12 studies
reported the adherence to slow breathing exercises and pa-
tients in 2 studies3,12 reported good adherence to the inter-
vention. In the study by Modesti et al,9 the number of
practice sessions (7 times/week requested) decreased from
5.1 times/week at baseline to 3.3 times/week at 6 months.
152 The American Journal of Cardiology (www.ajconline.org)

Figure 3. VSBE versus control: effect on SBP.

Figure 4. VSBE versus control: effect on DBP.

Thus, monitoring of long-term adherence is required to
obtain accurate information on the benefits of this
intervention.
The review was limited by the methodological quality of
the 6 studies, which were suggested have a low to moderate
risk of bias. The blinded methods of allocation concealment,
blinding of patients, therapists, and evaluators were not
completely provided by the enrolled studies. Furthermore,
we did not create funnel plots to show publication bias
because the number of included studies was limited. Further

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 Miscellaneous/Slow Breathing Exercise and Meta-Analysis
limitations are that the SD of mean change before and after
the intervention within the groups was transformed by a
formula; the extracted data were not very accurate; and the
sample was small, which could influence the interpretation
of the results.
Disclosures
The authors have no conflicts of interest to disclose.
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