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Increased heart rate variability during nondirective meditation

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 EURO PEAN
SO CIETY O F
Original scientific paper CARDIOLOGY ®

European Journal of Cardiovascular

Prevention & Rehabilitation

Increased heart rate variability during 0(00) 1–8

! The European Society of
Cardiology 2011
nondirective meditation Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1741826711414625
ejcpr.sagepub.com
Anders Nesvold1, Morten W Fagerland1, Svend Davanger2,
Øyvind Ellingsen3,4, Erik E Solberg5, Are Holen3,4, Knut Sevre1
and Dan Atar1,2

Abstract
Purpose: Meditation practices are in use for relaxation and stress reduction. Some studies indicate beneficial cardio-
vascular health effects of meditation. The effects on the autonomous nervous system seem to vary among techniques.
The purpose of the present study was to identify autonomic nerve activity changes during nondirective meditation.
Materials and methods: Heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS)
were monitored in 27 middle-aged healthy participants of both genders, first during 20 min regular rest with eyes closed,
thereafter practising Acem meditation for 20 min. Haemodynamic and autonomic data were collected continuously
(beat-to-beat) and non-invasively. HRV and BPV parameters were estimated by power spectral analyses, computed by
an autoregressive model. Spontaneous activity of baroreceptors were determined by the sequence method. Primary
outcomes were changes in HRV, BPV, and BRS between rest and meditation.
Results: HRV increased in the low-frequency (LF) and high-frequency (HF) bands during meditation, compared with rest
(p ¼ 0.014, 0.013, respectively). Power spectral density of the RR-intervals increased as well (p ¼ 0.012). LF/HF ratio
decreased non-significantly, and a reduction of LF-BPV power was observed during meditation (p < 0.001). There was no
significant difference in BRS. Respiration and heart rates remained unchanged. Blood pressure increased slightly during
meditation.
Conclusion: There is an increased parasympathetic and reduced sympathetic nerve activity and increased overall HRV,
while practising the technique. Hence, nondirective meditation by the middle aged may contribute towards a reduction
of cardiovascular risk.

Keywords
Autonomic nervous system, heart rate variability, nondirective meditation
Received 1 February 2011; accepted 2 June 2011

by healthy participants, characterized as reduced sym-

Introduction pathetic and increased parasympathetic activity. The
Over the last 40 years, various meditation techniques latter is known to be respiration dependent, and the
have been widely accepted in Western cultures and effects on sympathetic versus parasympathetic nerve
gradually become object of scientific scrutiny. Since activity may vary among methods related to volitional
the 1970s, several studies have focused on concentrative
meditation techniques and transcendental meditation
(TM).1,2 Over the past decade, a shift towards various 1
Oslo University Hospital, Norway.
mindfulness meditations3,4 and nondirective medita- 2
University of Oslo, Norway.
tion5 has occurred. Beneficial health effects of medita- 3
Norwegian University of Science and Technology, Norway.
4
tion are often attributed to positive changes in St Olavs Hospital, Norway.
5
autonomous nerve activity, manifesting as reduced Diakonhjemmet Hospital, Oslo, Norway.
heart and respiratory rates, reduced oxygen uptake,
Corresponding author:
and reduced circulating plasma catecholamine A Nesvold, Department of Cardiology, Oslo University Hospital, pb 4959
levels.6,7 Several authors report changes in heart rate Nydalen, 0424 Oslo, Norway
variability (HRV) during concentrative Zen techniques Email: annesv@ous-HF.no

Downloaded from cpr.sagepub.com at European Society of Cardiology on June 25, 2011

2 European Journal of Cardiovascular Prevention & Rehabilitation 0(00)
versus spontaneous breathing and other characteristics
of the practice.8–10
One study reported increased HRV by TM com-
pared with health education in patients with stable cor-
onary artery disease.11 HRV is recognized as an
independent inverse marker of cardiovascular
risk.12–14 Both genders show a decrease in HRV param-
eters with advancing age. Females have a dominant HF
power compared to males until the age of 45–50, pos-
sibly a cardioprotective mechanism.15
Since the first description of power spectrum analysis
of HRV,16 the frequency domain method has become the
preferred utility of assessing the short-term autonomous
cardiovascular control systems in subjects with sinus
rhythm. Beat-to-beat oscillations in heart rate are
induced by signals from the autonomic nervous system.
The power spectral density (PSD) analysis provides
information of how power (variance) distributes as a
function of frequency. Two main frequency components
have been identified: (i) the low-frequency spectrum (LF,
0.04–0.15 Hz), determined by mixed sympathetic-para-
sympathetic activity and baroreflex control, and (ii) the
high-frequency spectrum (HF, 0.15–0.4 Hz), linked to
parasympathetic (vagal) respiration dependent activity.
Their ratio (LF/HF) represents the sympathovagal bal-
ance. The PSD of all RR intervals (PSD-RRI) is a quan-
titative indicator of the short auto-regulatory function,
expressing the total variability and indirectly the global
activity of the autonomic nervous system.17
Series of beat-to-beat blood pressures (BP) may be
spectral analysed the same way as RRI series, and it has
been suggested that the low-frequency spectrum of the
blood pressure variability (LF-BPV) mirrors sympa-
thetic tone.18
Baroreflex sensitivity (BRS) is a measure of the
dynamic autonomous control of the heart rate caused
by variations in BP, defined as the altered RR interval
following changes in systolic blood pressure (ms/
mmHg). BRS decreases when the autonomic balance
is dominated by sympathetic activity and increases
through parasympathetic dominance.19,20
An editorial in BMJ 2003 stated that the overall evi-
dence of therapeutic effects of meditation is weak.21 A
more recent meta-analysis concluded that scientific
research on meditation practices must adhere to more
rigorous design, execution, and analysis of results.22 In
order to explore meditation scientifically, five method-
ological criteria have been suggested.23
Acem meditation is a nondirective technique wide-
spread in Scandinavia. It is based on a Western
approach, and psychological understanding of the eli-
cited mental processes. The method complies with
Cardoso’s criteria for quality meditation research.
Acem meditation does not require volitional direction
of attention towards specific subjective states of mind,
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nor any attempts to control the current mental content.
Thus, it is practised with a free mental attitude, similar
to some mindfulness meditations, and allows any
emerging thought, memory, emotion, or sensation to
pass through the awareness of the practitioner.
Further, it allows spontaneous normal breathing.24
Previous studies on Acem meditation have demon-
strated autonomous effects, such as lowering of heart
rate during meditation.25
The purpose of the present study was to identify
autonomic nerve activity changes by measuring HRV,
LF-BPV, and BRS during nondirective meditation
compared with regular rest in middle-aged participants
of both genders.
Methods
Participants
A total of 27 middle-aged participants (mean age 53.1,
range 34–63 years; 14 males) were studied. All were
gainfully employed, had incorporated the meditation
practice into their daily routines and were experienced
meditators (mean 31, range 10–41 years). Inclusion cri-
teria were freedom from known cardiovascular disease,
no concomitant vasoactive or psychotropic medication,
and sinus rhythm.
Procedures
Registrations were obtained between 09:00 and 13:00.
A 12-lead electrocardiogram (ECG) was taken in the
supine position. The participants rested sitting for
20 min in a quiet semi-darkened room with their eyes
closed, allowing thoughts to wander without perform-
ing any meditation tasks. After a short interval (about
1 min), the participants started 20 min of Acem medita-
tion. Each served as his/her own control.
Haemodynamic and autonomic data were collected
continuously (beat-to-beat) and non-invasively with
the Task Force Monitor (TFM; version 2.2.11.0,
CNSsystems, Medizintechnik, Graz, Austria). A bipo-
lar two-channel continuous ECG was recorded with
electrodes on the shoulders and hips and watched by
the observer present. An extensive haemodynamic pro-
file was derived by impedance cardiography through
band electrodes in the neck and on both sides of the
lower thorax and one neutral on the right leg.
Continuous arterial BP was measured by two cuffs
around the ground phalanxes of the index and middle
fingers of one hand, connected to the monitor via a
transducer strapped to the lower arm. Every
other minute, oscillometric arterial BP was measured
automatically with a cuff around the contralateral
upper arm.
Nesvold et al.
HRV was estimated by power spectral analysis of
the RR intervals. The variations of RRI (i.e. power)
within a given time frame were computed mathemati-
cally and expressed by amplitude (ms2/Hz) versus fre-
quency (Hz). Spectral analysis of the LF-BPV
estimated the low-frequency density (0.04–0.15 Hz) of
the beat-to-beat diastolic BP signals.
Spectral analyses was performed with a modified
Fast Fourier Transformation similar to the one pro-
posed by Bianchi et al.26 The TFM software applies
an adaptive autoregressive parameter algorithm.27,28
The spontaneous activity of the baroreceptors was
determined by means of the sequence method,29 which
analyses and displays rising sequences (rising systolic
BP, extended RR intervals) and falling sequences
(decreasing systolic BP, shorter RR intervals) sepa-
rately. All detected rising and falling sequences are
numerically registered as events. The TFM with algo-
rithms is thoroughly validated,30,31 and its mode of
operation is minimally disturbing to the participant.
The study design aimed to take into consideration
several possible confounders. More consistent and
apparent effects of meditation have been reported in
experienced meditators.32 To minimize circadian varia-
tions among the subjects,33 all registrations were under-
taken before noon. Due to the small sample, the gender
differences in HRV are reported, but not analysed sta-
tistically. Only sinus beats were included, as sinus
rhythm is necessary for reliable evaluation of the influ-
ence on the autonomic nervous system by HRV.34
Coronary artery disease, arterial hypertension in need
of treatment, heart failure, and diabetes mellitus
are known to reduce HRV,35–38 hence freedom from
such diseases was an inclusion criterion. None of
the participants used vasoactive medication, which
may affect sympathovagal balance.39–43 Before testing,
consumption of caffeine, tobacco, or alcohol, all
of which negatively affect HRV, was discouraged
for at least 24 hours.44–46 Although tables of
normal ranges do exist,47,48 autonomic cardiovascular
regulation parameters show large inter- and intra-indi-
vidual variations. Therefore, in the present study, with
a small sample size, we opted on a study design in
which each participant served as his/her control
during rest and meditation, thus constituting two
matched groups.
Statistics
For each participant, the TFM provided the mean
values of haemodynamic and autonomic variables
over the two time periods. The difference between the
mean value while resting and the mean value when
meditating was calculated. For variables with a
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3
sufficiently normal distribution, we used the paired
Student’s t-test confidence interval for the estimated
mean difference, and the paired samples t-test for the
hypothesis of no difference. If the distribution was
skewed, we estimated the difference between population
medians and used the Wilcoxon approximate normal
confidence interval and the Wilcoxon matched-pair
signed-rank sum test. SPSS version 16.0 and CIA
(www.som.soton.ac.uk/cia) were used for statistical
analyses.
Ethical considerations
The study was approved by the Regional Ethical
Committee of Health Region South of Norway. All
participants gave written informed consent. The study
did not involve therapeutic intervention or control.
Four participants were advised to seek a GP for
follow up of their hypertension.
Results
Heart rate and blood pressure variability
Compared with rest, both LF and HF power increased
significantly during meditation. Similar results were
observed in the PSD-RRI. No statistically significant
difference between rest and meditation occurred in the
LF/HF ratio. However, a LF/HF ratio of 1.3 at rest vs.
0.9 during meditation indicates a relatively stronger
parasympathetic mobilization. LF-BPV significantly
decreased during meditation (Table 1). For each indi-
vidual registration of HRV, the software provides a
three-dimensional illustration of the variations in the
discernible frequency bands. Figure 1 depicts the typi-
cal HRV variations during rest and meditation in one
male participant, and the PSD-RRI at one point in
time. The activity in the LF domain (0.04–0.15 Hz) is
relatively high during both sequences. As the partici-
pant begins to meditate, a distinct and persistent
increase of activity in the HF band (0.15–0.4 Hz) is
seen. Respiration and heart rates did not change signif-
icantly (Table 2). Of the total number of heartbeats in
both groups, 1.3% ectopic beats were excluded at rest,
2% during meditation.
Blood pressure and baroreflex sensitivity
Mean arterial systolic and mean BP increased signifi-
cantly during meditation, compared with rest, and there
was a non-significant increase in the mean diastolic BP
(Table 3). Four individuals were identified as clearly
hypertensive. One male had mean systolic/diastolic
4 European Journal of Cardiovascular Prevention & Rehabilitation 0(00)

Table 1. Median values of spectral analyses of low-frequency blood pressure variability (LF-BPV), low frequency heart rate variability
(LF-HRV), high frequency heart rate variability (HF-HRV), and power spectral density (PSD) variables of heart rate variability at rest
and during Acem meditation (n ¼ 27)

Rest median Meditation median Estimated difference between

Variable (IQR) (IQR) population medians (95% CI)a p-valueb

LF-BPV (mmHg2)c 5.1 (5–9) 3.6 (2–8) 2.5 (1.4 to 5.0) <0.001
LF-HRV (ms2) 199 (275) 261 (543) 63 (9 to 208) 0.014
HF-HRV (ms2) 115 (186) 165 (322) 52 (13 to 117) 0.013
PSD (ms2) 779 (765) 1234 (2992) 787 (121 to 2531) 0.012
IQR, Interquartile range. aWilcoxon approximate normal confidence interval. bWilcoxon matched-pair signed-rank sum. cMissing BPV values of one
participant.

1 01:14 Start recording

2 01:40 Starts rest
3 21:49 Stops rest
4 22:17 Starts meditation
5 42:28 Meditation stops
HRV-RRI

PSD
min
ms2 %
5
2500 40
40
36
35
2000 32
30 28
1500 25 24
3 4
20 20
1000 16
15
12
500 10 8
5 4
1 2
0 0 0
0.0 0.1 0.2 0.3 0.4 0.5 Hz

Figure 1. Three-dimensional illustration of representative heart rate variability changes in one male (55) at rest and during Acem
meditation The ordinate indicates the percentages of the HRV variations in the discernible frequencies, the abcissa the range of
frequencies (Hz) The time axis (right) shows that registration begins at timepoint 1, the participant starts to rest with closed eyes at 2,
stops rest after 20 min at 3. He begins to meditate at 4, and stops meditation after 20 min at 5. To the left, the power spectral density
(PSD) is displayed as a vertical bar in colours. The actual value is at the point of time shown by red line at 5. The colour of the bar
depends on the actual value (red, low PSD; green or blue, high PSD).

BP 173/107 mmHg at rest and 184/125 mmHg during

meditation. The mean BP of the remaining participants
was normal, but with a tendency to increase during
meditation. BRS, based on a comparable number of
events at rest and during meditation, showed no signif-
icant difference (Table 4).
Discussion
The novelty of this study is the marked increase in gen-
eral HRV power during non-directive meditation in
middle-aged to elderly participants of both genders.
Both the LF and HF components increased, as well

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Nesvold et al. 5

Table 2. Mean values of respiration and heart rates at rest and during Acem meditation (n ¼ 27)

Variable Rest Meditation Differencea p-valueb

Respiration rate/min 16.9  1.9 16.3  1.8 0.52 (0.050 to 1.9) 0.072
Heart rate/min 72.6  10.9 71.6  10.6 0.92 (0.15 to 1.98) 0.088
Values are mean  standard deviation or mean (95% confidence interval). aStudent t-test confidence interval. bPaired samples t-test.

Table 3. Mean values of systolic, diastolic, and mean arterial blood pressures (mmHg) at rest and during Acem meditation (n ¼ 27)

Variable Rest Meditation Differencea p-valueb

Systolic BP 125.9  14.0 128.7  15.3 2.76 (14.67 to 85) 0.006

Diastolic BP 85.7  9.4 87.2  11.4 1.50 (3.30 to 0.30) 0.098
Mean BP 96.8  9.8 99.0  11.1 2.20 (3.91 to 0.49) 0.014
Values are mean  standard deviation or mean (95% confidence interval). aStudent t-test confidence interval. bPaired samples t-test.

Table 4. Mean of baroreflex sensitivity (BRS) and of the arithmetic mean of all sequences at rest and during Acem
meditation (n ¼ 27)

Variable Rest Meditation Differencea p-valueb

BRS (ms/mmHg) 10.4  4.6 9.9  4.5 0.5 (0.81 to 1.89) 0.42
Number of events 156.2  87.5 164.2  93.6 7.9 (28.6 to 12.7) 0.42
Values are mean  standard deviation or mean (95% confidence interval). aStudent t-test confidence interval. bPaired samples t-test.

as the PSD-RRI, when compared with rest. There was a
relatively stronger parasympathetic mobilization. The
significant reduction in LF-BPV substantiates the
reduced sympathetic tone.
Figure 1 illustrates the findings representatively. It
shows that nondirective meditation is not psychobiolo-
gically inert and it supports the idea that certain forms
of meditation may induce active, rather than quiescent,
cardiac dynamics.49,50 The figure aptly depicts the sub-
jective experience of the performer: the peaks and lows
may correlate with the variations in the stream of
consciousness.
The respiration rate did not differ between rest and
meditation. This shows that the HRV changes observed
in this study were in fact caused by the mental tech-
nique and not by slow breathing, as observed in other
techniques.51,52
In line with previous findings from other meditation
techniques, no substantial change in the acute mean
heart rate was observed, which supports the notion
that HR is of limited value in assessing the complex
dynamics of meditation effects.53
The increase in blood pressure during meditation
merits comment. No description of beat-to-beat BP
variations during meditation is found in the literature
In the meta-analysis by Ospina et al.22 three studies
compared TM with no treatment (NT), including a
total of 129 healthy participants (TM ¼ 67, NT ¼ 65)
over 312 months. The combined estimate of changes
in BP showed a small, but non-significant improvement
(reduction) in favour of no treatment. Two other stud-
ies22 compared TM with concentrative progressive
muscle relaxation (PMR), involving a total of 179
hypertensive patients (TM ¼ 90, PMR ¼ 89). A com-
bined estimate of changes in sBP indicated a significant
reduction in favour of TM. Long-term reduction in BP
in daily life has also been demonstrated with Acem
meditation.54
In the present sample, four participants had hyper-
tension, they did not fulfil one inclusion criterion.

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6 European Journal of Cardiovascular Prevention & Rehabilitation 0(00)
However, as they were unaware of their condition at
inclusion, and as the percentage of hypertensives in the
sample (about 15%) reflects that of the general non-
treated adult population, their data were included for
statistical analysis. As a group, the four hypertensive
individuals (resting BP >130/100 mmHg) had equal
median LF-BPV, lower median LF-HRV and
HF-HRV, but higher median PSD at rest and during
meditation than the normotensives. Their mean respi-
ratory and heart rates were higher during both
sequences. No significant change in BRS between rest
and meditation emerged when the hypertensive individ-
uals were excluded from analysis. Hypertension is
known to impair autonomic function parameters sub-
stantially, particularly in postmenopausal females.55
Hence, one may argue that the presence of hypertensive
participants makes the HRV findings even more robust.
The median LF-BPV at rest and during mediation
was almost equal between the genders. The females had
lower median LF-HRV during both sequences, still
there was a notable increase in both gender groups
(median LF-HRV females at rest 155 ms2, during med-
itation 166 ms2, males at rest 270 ms2, during medita-
tion 282 ms2). For both genders, median HF-HRV was
fairly equal during both sequences. The males had a
more pronounced increase in median PSD during
meditation.
None of the participants had known coronary artery
disease (CAD). A possible clinical implication of the
HRV findings involves patients with CAD. Intensive
supervised relaxation practice after a cardiac ischaemic
event has been shown to enhance recovery and contrib-
ute to secondary prevention, being an important ingre-
dient of cardiac rehabilitation. Increased HRV seems to
be an important measure of successful secondary
prevention.56,57
Limitations of the study
There was no non-meditating control group and it was
not prospective. All participants were experienced med-
itators. Thus, the findings give little information about
the effects for beginners, and for patients at risk.
Conclusion
Nondirective meditation reduces sympathetic and
increases parasympathetic nerve activity and overall
HRV in the middle aged of both genders. Regular prac-
tice may help to preserve HRV for those of middle age
and older, and thus may contribute to reduce cardio-
vascular morbidity and risk. Further scientific scrutiny
should be directed to a larger prospective study involv-
ing novice meditators and patients at risk, with a non-
meditating control group.
Downloaded from cpr.sagepub.com at European Society of Cardiology on June 25, 2011
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
Of the authors, Anders Nesvold, Svend Davanger, Øyvind
Ellingsen, Erik E Solberg and Are Holen are affliliated with
Acem School of Meditation, an international non-for-profit
organization. Morten W Fagerland, Knut Sevre and Dan
Atar have no such affiliation.
Parts of the work have been presented as a poster (P-20) at
the International Society for Heart Research (ISHR) North
American Section Meeting, 26 May 2009, Baltimore MD,
USA and a poster (P-013) at the annual meeting of the
Norwegian Society of Cardiology, 8 June 2010, Oslo,
Norway.
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