ABC | Volume 113, Nº6, December 2019

Editorial Silveira & Stein Evidence-based alternative therapies that “touch the heart” Arq Bras Cardiol. 2019; 113(6):1059-1061 particularly: stress, depression and anxiety reduction; increased functional capacity; BP reduction and improvement of lipid profile. 6,7 Furthermore, studies in elderly patients have shown a significant improvement in balance, reduced risk of falling, decreased muscle and joint pain, improvement in osteoporosis and even improved or maintained cognitive performance. 6 Due to a scientific gap in assessing the impact of TC practice on patients with coronary artery disease - CAD, 8 the Exercise Cardiology Research Group of the Hospital de Clínicas de Porto Alegre studied the effect of this practice on 61 post‑AMI patients. 9 They were randomized for practicing TC for 60 minutes, three times a week or for stretching exercises (control group). After 12 weeks of training, the group who practiced TC showed significant improvement in peak oxygen consumption (14%= 3.1 mL.kg -1 .min -1 ), whereas the stretching group did not show any improvements. Similar effects were found in some studies with HF patients, showing that this practice can impact positively on functional capacity increment. Yoga The last of the three oriental practices mentioned is the one which has the largest body of evidence in favor of potential benefits, be it due to a greater volume of studies or to the fact that the practice is more widespread in the West. This practice dates back to 1,500 years B.C. and is present in all Hindu holy books (Vedas, Bhagavad Gita and Upanishads). The word Yoga derives from Sanskrit and means union, and its practice is divided into three components, namely: the asanas , which are the different yogic postures; the pranayamas , which are breathing exercises and the dhyanas , which are basically meditative practices. Different studies have shown the physiological benefits of its practice, among which are metabolic (BP reduction, improvement in lipid and glycemic profile), anti-inflammatory (decrease in C-reactive protein and cytokines), immunological (enhanced CD4 T lymphocytes and telomerase activity), neuroendocrine (decreased cortisol, adrenaline and aldosterone) and autonomic (increased HRV and improved baroreflex sensitivity) effects. 10,11 The evidences also indicate an increase in oxygen consumption and strength in patients with HF, decreased angina and increased functional capacity in individuals with CAD, as well as reduction of atrial fibrillation symptoms. 10 A systematic review and meta-analysis assessed the effects of Yoga on some cardiovascular risk factors, and found a mean reduction of 5 mmHg in systolic and diastolic pressures, body mass and body mass index reduction, LDL and triglycerides reduction, as well as increased HDL cholesterol levels. 11 More recently, a group of researchers from different institutions of Rio Grande do Sul carried out an RCT enrolling patients with HF and preserved ejection fraction. The authors compared the effects of Yoga combined with breathing techniques with a control group, in accordance with a recently published protocol. 12 Positive effects were found on inspiratory muscle force and autonomic modulation assessed by HRV in the group exposed to the intervention (non-published data). Laughter therapy Laughter is more than a visual and vocal behavior, it is always accompanied by a series of physiological changes, including spasmodic contractions of skeletal muscles, increased heart rate due to catecholamine release and hyperventilation with increased residual air exchange, leading to increased oxygen saturation. 13 The study of the effect of laughter and humor and its psychological and physiological impacts on the human body is called Gelotology. The first experiments in this area were carried out in the 30s, and assessed the effect of laughter on muscle tone and the respiratory mechanism in laughter. The increase in the number of studies in this area is based on the assumption that, if bad humor is harmful for the cardiovascular system, good humor (laughter therapy) and its physical changes might be beneficial. One of the few studies that have used Laughter Therapy in unhealthy individuals was performed by Tan et al. 14 In this experiment, 48 diabetic patients with recent AMI were divided into two groups. The 24 patients in the experimental group were assigned to view a humor video for 30 minutes daily, as an adjunct to standard therapy. After a 1-year follow-up, the authors observed a significant reduction in BP compared with the patients from the control group. Furthermore, patients exposed to comedy had fewer episodes of arrhythmias, less use of nitroglycerin for angina and lower incidence of recurrent MI (only two vs. ten cases in the control group). Finally, an RCT is in progress which aims at assessing hemodynamic biochemical responses of patients with stable CAD undergoing Laughter Therapy. 15 In this trial, patients of both sexes, aged ≥ 18 years, monitored regularly in a university hospital in the South region of Brazil, are being allocated to an intervention group (who will watch a 30-minute comedy film) or to a control group (who will watch a 30-minute neutral documentary). It is expected that some results will already be available by 2020. Conclusion We live at a time when Cardiology accelerates towards new technology, when, for instance, artificial intelligence emerges as a true “partner” of physicians. At the same time, ancient traditions such as Meditation, TC and Yoga, in addition to something as delightful as laughter, have been tested and may be used in the management of patients with different cardiomyopathies. Even though these therapies do not present a very robust body of evidence and are usually supported by small efficacy studies, they are simple, safe and low-cost therapeutic alternatives which, in addition to improving quality of life, can positively influence the physiological and biochemical parameters of these individuals. Finally, there is a perspective that, as the number of adherents of these practices increases, larger and better-designed studies will be carried out, which may establish the real role of these practices, whether in prevention or treatment of cardiovascular diseases. 1060