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Yoga shoptalk, October, 2003

Should Mitral Valve Prolapse (and mild Mitral Valve Regurgitation) limit my hatha yoga practice? In particular, I worry about inversions. I was told to watch my blood pressure carefully so as not to put additional strain on the weak valve, and since blood pressure gets reversed in inversions, it seems like they could be a problem. My solution, in the absence of any input from physicians, has been to do inversions infrequently and only hold them briefly. I focus more on inversions like the plow and bridge, where blood pressures aren't as extreme, and almost never do headstands. Am I being overcautious? Is there any other category of poses that should make me wary? I did learn while reading your book that I was habitually lifting incorrectly, using pneumatic pressure in the thorax instead of hydraulic pressure in the abdomen to protect my spine. Now I know better, and I try always to use intra-abdominal hydraulic pressure so I don't increase pressure in my chest and potentially aggravate that already weak valve.

Answer: I generally avoid fielding medical questions such as this, since my background is not clinical medicine but anatomy and physiology, so I posed your question to a cardiologist who has had more than 25 years experience with hatha yoga, both as a practitioner and as a medical consultant for patients and teachers. His comments (edited for this column for the non medical professional) follow below:

Blood pressures in the headstand are reflective of both gravity and one’s skill in coming into and remaining in the posture. As far as gravity is concerned, the measured blood pressure above or below the heart depends on the arterial blood pressure measured at the level of the heart (that is, one's baseline blood pressure, which is nominally 120/80 mm Hg both upright and inverted) plus or minus how far below or above the heart the pressure is measured. See figures 8.2a and 8.2b in Anatomy of Hatha Yoga for calculated arterial blood pressures standing and inverted. The figures shown there assume that muscular work and anxiety involved in doing the posture are minimal, as is expected in the case of an experienced practitioner. If you can’t do the posture easily, it will be better to consider it contraindicated. Regarding the heart valves, pressure stresses on the heart itself and its valves (including the mitral valve) do not have to do with inversion itself since the heart sees the same approximate pressure both upright and inverted. Again, see figures 8.2a and 8.2b, and note the blood pressure in muscular arteries at heart level is 120/80 mm Hg in both cases, at least for someone who does not create undue strain coming into and remaining in the pose. The pressures within the mitral valve itself are more complex to consider (reference: any textbook of cardiovascular physiology), but are logical and are roughly derivative of and related to arterial blood pressures at heart level.

Having said all this, and after having thereby perhaps encouraged you to go ahead and do the headstand, I should mention that the diagnosis of mitral valve prolapse involves a spectrum of severity, and recommendations for exercise and physical activity vary according to the severity of the condition. Specific guidelines have been detailed for isometric and aerobic exercise for people with cardiac conditions of several kinds, including mitral valve prolapse and mitral regurgitation, and these guidelines were published in what is called the "26th Bethesda Conference Guidelines." See http://www.acc.org/clinical/bethesda/beth26.htm. For your particular case (assuming that you are able to do the headstand without undue muscular stress), it would be wise to consult a cardiologist who is familiar with these guidelines and actually do the posture in his or her presence, at which time he or she would be able to make an educated judgement as to whether it is advisable for you personally to practice the pose.

Assuming it is OK for you to do the headstand, maintaining the flow of breath can help avoid excess isometric muscular tension beyond what is needed to support the posture against gravity. Poses such as the peacock, on the other hand, in which much or most of the body weight is placed on the abdominal wall, will certainly lead to elevated arterial blood pressures. And finally, in yoga postures generally as well as much of daily life (as you are already aware from your comments about the inadvisability of using pneumatic pressure in the chest to support postures), we advise always keeping the airway open unless holding the breath is integral to the posture, as in the case of uddiyana bandha after a full exhalation (discussed in detail in chapter three of Anatomy of Hatha Yoga) or as in the case of a pranayama practice of breath retention after inhalation as taught by a competent and conservative teacher.