J Physiol 594.
24 (2016) pp 7163–7164
JOURNAL CLUB
Passive heat therapy: the next
hot thing for cardiovascular
health!
Daniel Lazzam1 , Bridget Wang1 ,
Eric Jong1 and Pratiek N. Matkar1,2
1 rectal temperature greater than 38.5°C for
Keenan Research Centre for Biomedical
Science and Li Ka Shing Knowledge
Institute, St. Michael’s Hospital, Toronto,
Ontario, Canada
2 jects in both groups were matched for sex,
Institute of Medical Science, University of
Toronto, Toronto, Ontario, Canada
Email: pratiek.matkar@mail.utoronto.ca
Cardiovascular disease is currently the
The Journal of Physiology
leading cause of death in developed
countries across the globe, with myriad
risk factors that modern life has only
exacerbated. As such, treatments and life-
style changes that alleviate the risk of cardio-
vascular disease are of great relevance. While
factors like exercise and good diet are known
to have such ameliorative effects, patients
at high risk of developing cardiovascular
diseases are often elderly or obese, and thus
may have difficulty exercising on a regular
basis. Furthermore, individuals with lower
incomes often cannot afford to eat healthily,
or such a diet is logistically impossible for
them. These factors will only be exacerbated
by rapidly rising food prices and increasing
populations aggravating socioeconomic
phenomena such as food deserts, residential
areas devoid of groceries or healthy food
options (Rehm et al. 2015). Thus, medically
subsidized alternatives to these options are
extremely important to explore for those
whom a good diet or frequent exercise may
be difficult or infeasible.
In recent years, several studies have
examined thermal therapy as one such
alternative, primarily through methods
such as saunas and bathing (Imamura
et al. 2001; Hu et al. 2012). While the
efficacy of thermal therapy on cardio-
vascular health has at this point been
demonstrated by multiple studies, the
underlying mechanisms are less under-
stood. However, a recent publication in
The Journal of Physiology (Brunt et al.
2016) has helped to elucidate some of these
mechanisms. In the paper, Brunt et al.
(2016) performed an 8 week study on a
cohort of 20 subjects in which the subjects
either underwent heat therapy 4–5 times a

C 2016 The Authors. The Journal of Physiology 
C 2016 The Physiological Society
7163
week for a total of 90 min or were immersed
in thermoneutral water as an osmotic and
hydrostatic control. The subjects assigned
to heat therapy were immersed in 40.5°C
water, a temperature sufficient to maintain
60 min. In contrast, the rectal temperature
of the control group remained within
0.2°C of the original temperature. Sub-
age, height, body mass index and weight,
ensuring a representative control group. The
authors of the study took a multi-pronged
approach in determining the mechanism
of action of heat therapy by measuring
a variety of processes that they hypo-
thesized could contribute: flow-mediated
dilatation, superficial femoral dynamic
arterial compliance, aortic pulse wave
velocity, carotid intima media thickness,
and mean arterial blood pressure. These
measurements were taken at the start of the
study and every 2 weeks thereafter.
The literature has suggested that part
of the mechanism by which heat therapy
ameliorates cardiovascular health is
through alleviation of arterial stiffness (Hu
et al. 2012). Consequently, Brunt et al.
(2016) hypothesized that flow-mediated
dilatation and superficial femoral dynamic
compliance would increase with regular
heat therapy. Indeed, flow-mediated
dilatation saw an immediate and significant
increase with heat therapy when compared
to the control group. While it appeared
to drop temporarily during week 4, when
corrected for shear stress, this outlier
returned to the logarithmic pattern
shown earlier. The trend is enormously
encouraging as it implies that while
increased use of heat therapy will show
greater returns, only a brief initial treatment
is needed for significant benefits. As the
article mentions, increases in flow-mediated
dilatation as small as 2% have shown a
15% reduction in risk for cardiovascular
disease, and an increase greater than 2% was
shown after only 2 weeks, demonstrating
the immediate clinical relevance of heat
therapy. While carotid arterial compliance
did not show a similar response to heat
therapy, being statistically unchanged from
the control, superficial femoral dynamic
arterial compliance did display a significant
increase also following a logarithmic
pattern after heat therapy, reinforcing the
results of earlier studies showing decreases
in arterial stiffness (Hu et al. 2012; Brunt
et al. 2016).
The authors also investigated other
outcome measures to assess risk for
cardiovascular disease such as pulse wave
velocity, arterial wall thickness in both
the carotid and femoral arteries, and
blood pressure. A significant downwards
trend was observed in pulse wave velocity
when compared to week 0, although
not compared to the control group,
showing that further investigation is
required. However, other results were more
promising; while arterial wall thickness in
the femoral arteries showed no significant
difference, carotid wall thickness showed
significant decreases, possibly due to the
breakdown of atherosclerotic plaque, a
finding of clinical relevance. While more
detailed studies of the mechanism of this
effect are required, this is an enormously
promising result. Furthermore, the study
also showed significant reductions in both
mean and diastolic blood pressure. While
these reductions were only 4 mmHg, the
duration of the study was fairly short by
the standards of a preventative measure, and
the results feasibly could increase with time.
Finally, as the article states, this reduction
is found in healthy individuals; thus, it is
plausible that there would be a greater drop
from the elevated blood pressure seen in
individuals with cardiovascular disease if
heat therapy was used as a treatment rather
than a preventative measure (Brunt et al.
2016).
Brunt et al. (2016) opened up a
variety of avenues for further in-depth
studies, such as investigations into the
sources of arterial wall thickness reduction
as mentioned above, by studying the
mechanisms by which heat therapy
ameliorates risk for cardiovascular disease
in breadth. However, even without such
investigation, the results of the research
article are remarkably useful with regards
to preventative measures against cardio-
vascular illness. The logarithmic increase
in flow-mediated dilatation found by the
authors suggest this treatment is useful even
in the short term for those with elevated
risk factors. Moreover, a treatment with
the potential for non-invasive reduction
of atherosclerotic plaque could be a
powerful tool to dramatically reduce risk of
DOI: 10.1113/JP273213
7164
myocardial infarction, although the risk of
embolism would also need to be evaluated.
Furthermore, heat therapy may also be
useful in the long term in healthy patients,
both to reduce the risk factors already
described and potentially to lower pulse rate,
a trend the authors described, but which did
not reach full significance during the time
constraints of the study. Lowering blood
pressure in the long term could also help
to reduce arterial strain and atherosclerotic
buildup, as well as many other factors,
leading to a healthier long-term cardio-
vascular system. Thus, it is clear that results
of the study could be of clinical use both
in the short and long term as a preventive
measure.
However, additional investigations are
warranted. Because the study in question
only addressed the effects of heat therapy
on young, healthy patients, the therapeutic
value of the treatment in patients with
significant risk factors for cardiovascular
illness such as severely elevated blood
pressure, atherosclerosis, or obesity is
unknown. It also would have been
worthwhile to comment on the potential
dangers of heat therapy for certain patients,
particularly those with aortic stenosis,
unstable angina, severe orthostatic hypo-
tension, pregnancy, or any history of recent
myocardial infarction, as these adverse
effects have been shown in some studies in
the literature. Particularly, persons prone to
orthostatic hypotension should avoid heat
therapy because of the significant decrease
in blood pressure, which usually occurs
immediately after heat therapy (Laukkanen
et al. 2015). Thus, heat therapy requires
significantly more research before being of
use as a preventative method or treatment
Journal Club
for patients with cardiovascular disease,
rather than to solely prevent its incidence.
Finally, the study that inspired Brunt et al.
(2016) showed diminishing results from
heat therapy in older patients, meaning
that it may not be as effective as a pre-
ventive treatment in elderly patients (Hu
et al. 2012), who also have elevated risks for
cardiovascular illness. This phenomenon
should be studied in greater depth to
verify it because the study in question
only investigates the effects of footbaths
on cardiovascular health. Therefore, this
result may have been a consequence of
diminished peripheral circulatory function
in the elderly. Furthermore, the study in
question showed that the use of footbaths
only raised tympanic temperature to slightly
over 37°C, whereas Brunt et al. (2016)
raised rectal temperature above 38.5°C, a
difference in temperature that may increase
the efficacy of heat therapy in the elderly.
Nonetheless, if valid, the mechanisms
contributing to this reduction in efficacy
should also be studied to confirm its
incidence, and the effectiveness of heat
therapy in the elderly should be examined
regardless due to their high incidence of
cardiovascular complications.
With the growing incidence of cardio-
vascular disease and an ageing global
population, finding viable treatments and
preventative measures for patients is
becoming increasingly important. Having a
large array of possible options for treating
and preventing cardiovascular disease is
especially crucial in treating a diverse
patient population, some of whom may
be incapable of exercise or have other
circumstances preventing ideal cardio-
vascular health. This study helps to expand

C 2016 The Authors. The Journal of Physiology 
J Physiol 594.24
this array by delving into the mechanisms
by which heat therapy improves cardio-
vascular health. It is heartening that cardio-
logy research is finding solutions to an
increasingly significant health problem. Yet
there is still much to be discovered, and more
clinical trials involving heat therapy need to
be performed to understand the treatment
in-depth and add to our current knowledge.
References
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Minson CT (2016). Passive heat therapy
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Hu Q, Zhu W, Zhu Y, Zheng L & Hughson RL
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Imamura M, Biro S, Kihara T, Yoshifuku S,
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Additional information
Competing interests
None declared.
C 2016 The Physiological Society