December 27, 2019
Several recent studies on Transcendental Meditation (TM)™ have caught my attention; these studies suggest we should expand our treatment protocols for patients with coronary heart disease to include TM.
Let’s start with a study by Bokhari et al published in the Journal of Nuclear Cardiology in September 2019. These researchers asked whether adding TM to standard therapy or standard therapies along with a cardiac rehab exercise program might do these patients any good. They recruited fifty-six African American patients with coronary heart disease, including those with recent heart attack, coronary artery bypass, or angina. The patients were divided into four groups and assigned to cardiac rehabilitation (CR), Transcendental Meditation (TM), Transcendental Meditation plus cardiac rehabilitation (CR+TM), or just usual care.
Testing was done at baseline and after 12 weeks. Patient response was assessed using a state-of the-art technique, myocardial flow reserve (MFR), that was assessed by 13N-ammonia positron emission tomography (PET). This technique is fast becoming the gold-standard of heart function assessment. This method of measuring cardiac flow reserve is increasingly being used “… to assess coronary artery disease, to guide revascularization decisions with more accuracy, and it allows robust quantitative analysis of both regional myocardial blood flow (MBF) and myocardial flow reserve (MFR).”
Participants in the TM groups were taught Transcendental Meditation and instructed to practice twice a day for twenty minutes.
Of the 56 initial study participants, 37 completed the post-testing. Myocardial blood flow increased by 20.7% in the group that did both Transcendental Meditation and cardiac rehabilitation. Blood flow in the group that practiced Transcendental Meditation alone increased 12.8%. Those in the cardiac rehabilitation only group improved by only 5.8%. The patients who received only “usual treatment” declined; their myocardial blood flow decreased by -10.3%.
Granted this was a small study but these results suggest that getting patients to practice TM at home yielded twice the benefit as having them attend cardiac rehab classes. Add the numbers up, compared to the ‘usual’, getting these patients to also do cardiac rehab to exercise their hearts and TM to rest their minds increased cardiac blood flow by 31%. That’s enough of a difference we should pay attention
Transcendental Meditation was brought to the west more than half a century ago by the Indian Maharishi Mahesh Yogi. His technique became very popular in the 1960s, and 1970s. Promoters of the practice adopted the idea that this technique could and should be evaluated scientifically and encouraged researchers to study the effect it had on practitioners. Wallace, Benson and Wilson were the first to describe the wakeful hypometabolic state induced by the practice in the literature in 1971.  The earliest clinical trial listed in PubMed is Dilbeck’s 1977 report that 2 weeks of practicing TM (n=33) produced a significant decrease in measured anxiety compared to sitting with the eyes closed. 
Practitioners and researchers described a distinct state of consciousness induced by the practice that differed from sleeping, dreaming or normal wakefulness, a state of restful alertness, what they labeled a “fourth state of consciousness”.  “The purpose of meditation is the elimination or reduction of thought processes, the deceleration of the inner dialog of the mind. This reduction of the thought process aims to increase this state of higher consciousness and, thus, could lead to a great sense of physical and mental tranquility.” 
Research on TM has been aided by the comprehensive training program instructors undergo and the standardization of instruction. The resultant reproducibility and availability of subjects along with active encouragement by the organization teaching the technique has over the intervening years led to the publication of a substantial body of scientific data describing the effects of the practice.
The hypothesis that practicing TM might reduce risk of CVD was presented early on; remember that now discarded premise that highly stressed Type A personalities were more prone to heart attacks? Randomized controlled trials of the effects of TM on hypertension were first published in the mid-1990s.  
In a 2004 review on TM and heart disease, Walton et al suggested that at that time there was already a substantial body of research that comprised over 600 papers. That is the most recent published tally that I’ve come across, but it is clearly out of date. There have been at least 3 dozen papers on TM and heart disease published in the past two decades since then. This new Bokhari paper just mentioned is one of a half a dozen recent papers to suggest TM has potential benefit for patients with heart disease.
A number of theories have been put forth to explain why TM might offer protection: “Evidence for its ability to reduce traditional and novel risk factors for CVD includes: 1) decreases in blood pressure, 2) reduced use of tobacco and alcohol, 3) lowering of high cholesterol and lipid oxidation, and 4) decreased psychosocial stress. Changes expected to result from reducing these risk factors, namely, reversal of atherosclerosis, reduction of myocardial ischemia and left ventricular hypertrophy, reduced health insurance claims for CVD, and reduced mortality, also have been found with TM practice. Research on mechanisms suggests that some of the CVD-related benefits as a result of this technique could arise from normalization of neuroendocrine systems whose function has been distorted by chronic stress.”
Although those connected with the TM movement have long argued that the practice is distinct from other meditation techniques, the scientific literature often groups all meditative techniques under similar search headings and as a result it is hard to distinguish between studies which meditation exactly the practitioners were doing. Thus, it is not always easy to discern whether a study is describing participants following “do it yourself” instructions (for example those published in The Relaxation Response by Herbert Benson in 1976 on how to imitate TM meditation, or those following online instructions for mindfulness meditation, or some technique they learned at a yoga studio). Followers of Maharishi always insist that the TM technique they practice is unique and that these other practices do not have the same effects.
Neurohormonal effects of TM have been documented in numerous studies and were summed up by Newberg & Iversen in 2003. They reported that practicing TM increased GABA, glutamate, and dopamine in the brain while decreasing cortisol and noradrenaline.
The results reported in this current Bokhari study are in line with earlier publications. Data published in 2012 in Circulation also suggested a significant benefit. In a randomized controlled trial (n=201) of African Americans with coronary heart disease (CHD), following endpoints of all-cause mortality, myocardial infarction (MI), or stroke, during a 5.4 year follow up there was a 48% reduction in the TM group. 
An October 2019 paper by Schneider et al, reported that in a randomized controlled trial TM prevented left ventricular hypertrophy. In this study, African American adults (n=85) were assigned to either a TM intervention or a health education control group. At baseline and six-month follow up, participants left ventricular mass index (LVMI) were compared. The TM group’s LVMI was significantly lower.  That’s what we want to see.
TM researchers routinely select African Americans as study participants for their cardiovascular studies. The authors of these studies explain this recurring to recruitment as due to the fact that African Americans have a higher than average risk of heart disease and that this increase may be a result of psychosocial stress. Thus, a stress reducing intervention might have a greater impact on their relative risk than it might on the general population. One would assume that their results should still translate to wider populations but one must wonder if TM ‘works better’ in Blacks.
Of course, one of the weaknesses of all of these TM studies is the amount of personal contact that the TM practitioners receive from their instructors as they learn the technique. This attention might produce a not insignificant placebo effect. Even if this were the case, one might still argue that the ends justify the means in that anything that reduces cardiovascular mortality to the extent reported with so little risk is desirable.
The other reservation that some may have about these research papers is that they are consistently done by adherents or proponents of this technique and one might question their objectivity. Truthfully, similar questions about objectivity could be raised about a good percentage of other studies, especially when the research is sponsored by financial interests who desire specific outcomes.
The bottom line remains that practicing TM may help and it is unlikely to hurt. Currently this meditation technique is taught by a non-profit organization. Their sliding scale fee-schedule is posted on their website and is a model of transparency that many of us might emulate.
The American Heart Association came to a similar but more eloquently written conclusion in a 2017 position paper on meditation, writing in part:
“Studies of the effects of meditation on cardiovascular risk have included those investigating physiological response to stress, smoking cessation, blood pressure reduction, insulin resistance and metabolic syndrome, endothelial function, inducible myocardial ischemia, and primary and secondary prevention of cardiovascular disease. Overall, studies of meditation suggest a possible benefit on cardiovascular risk, although the overall quality and, in some cases, quantity of study data are modest. Given the low costs and low risks of this intervention, meditation may be considered as an adjunct to guideline-directed cardiovascular risk reduction by those interested in this lifestyle modification, with the understanding that the benefits of such intervention remain to be better established…” 
The bottom line remains that practicing TM may help, and it is unlikely to hurt. Currently this meditation technique is taught by a non-profit organization. Their sliding scale fee-schedule is posted on their website and is a model of transparency that many of us might emulate.
Refer patients to the national organization’s website for further information about learning the technique and finding a certified instructor: TM.org
 Tsj O, Rjj K, JH, M W, FM VZ Myocardial blood flow and myocardial flow reserve values in 13N-ammonia myocardial perfusion PET/CT using a time-efficient protocol in patients without coronary artery disease. Eur J Hybrid Imaging. 2018;2(1):11.
 Bokhari S, Schneider RH, Salerno JW, Rainforth MV, Gaylord-King C, Nidich S. Effects of cardiac rehabilitation with and without meditation on myocardial bloodflow using quantitative positron emission tomography: A pilot study. J Nucl Cardiol. 2019 Sep 16.
 Wallace RK, Benson H, Wilson AF. A wakeful hypometabolic physiologic state. Am J Physiol. 1971;221(3):795-9.
 Dillbeck MC. The effect of the Transcendental Meditation technique on anxiety level. J Clin Psychol. 1977 Oct;33(4):1076-8.
 Bloomfield HH. TM: Discovering inner energy and overcoming stress. New York: Delacorte Press; 1975.
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 Alexander C, Schneider R, Staggers F, et al. A trial of stress reduction for hypertension in older African Americans (part II): sex and risk factor subgroup analysis. Hypertension. 1996;28:228–237.
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 Newberg AB, Iversen J. The neural basis of the complex mental task of meditation: neurotransmitter and neurochemical considerations. Med Hypotheses. 2003;61(2):282-91
 Schneider RH1, Grim CE, Rainforth MV, Kotchen T, Nidich SI, Gaylord-King C, Salerno JW, Kotchen JM, Alexander CN. Stress reduction in the secondary prevention of cardiovascular disease: randomized, controlled trial of transcendental meditation and health education in Blacks. Circ Cardiovasc Qual Outcomes. 2012 Nov;5(6):750-8.
 Schneider RH1, Myers HF2, Marwaha K1, et al. Stress Reduction in the Prevention of Left Ventricular Hypertrophy: A Randomized Controlled Trial of Transcendental Meditation and Health Education in Hypertensive African Americans. Ethn Dis. 2019 Oct 17;29(4):577-586.
 Levine GN, Lange RA, Bairey-Merz CN, et al. Meditation and Cardiovascular Risk Reduction: A Scientific Statement From the American Heart Association. J Am Heart Assoc. 2017;6:e002218.