Anticoagulation and Yoga Exercises: Can I Stand on My Head While on Coumadin?

A 67 yo CM was admitted to the hospital with blurry vision for 3 days. He has been in a remarkably good health apart from an episode of atrial fibrillation 6 years ago. The patient has been running 5 miles every day for the last 20 years and has practiced yoga daily.

PMH: Atrial fibrillation s/p catheter ablation 6 years ago

Medications: None

Physical examination:
HR 140
CVS: Clear S1S2, irregularly irregular rhythm
Chest: CTA (B)
Abdomen: Soft, NT, ND, +BS
Extremities: no c/c/e
Neurological examination: Nonfocal

What tests would you order?
EKG
CT of the brain
CBC, BMP

What happened?
EKG showed AFib with RVR
CT brain showed an occipital ischemic stroke

What happened next?
Heart rate was controlled with metoprolol. The neurology consultant recommended an MRI of the brain and MRA which confirmed an occipital ischemic stroke. Carotid ultrasound and TTE were normal.

His visual changes noted on admission have resolved completely. He has no motor or sensory deficits.

The neurologist advised against anticoagulation with Heparin or LMWH in order to decrease the risk for hemorrhagic conversion of the infarct. Coumadin was started.

Patient wanted to know if he can perform his yoga routine, specifically headstand, while on Coumadin. Headstand is a an exercise position in which one supports oneself vertically on one's head with the hands braced for support on the floor.

What would you answer?
Not surprisingly, there are no published studies comparing the incidence of hemorrhagic stroke in anticoagulated patients performing headstands to the ones who do not.

However, uncontrolled hypertension in patients on anticoagulation is related to increased risk for hemorrhagic stroke (1). Headstand increases intracranial pressure (2) and therefore we advised the patient against performing this exercise.

Final diagnosis: Occipital stroke due to atrial fibrillation

What did we learn from this case?
Blood pressure should be well-controlled in patient who will need long-term anticoagulation. Exercises which lead to increased intracranial pressure should probably be avoided.

References
1. Avoiding central nervous system bleeding during antithrombotic therapy: recent data and ideas. Stroke. 2005 Jul;36(7):1588-93. Epub 2005 Jun 9.
2. Intraocular pressure changes and ocular biometry during Sirsasana (headstand posture) in yoga practitioners. Ophthalmology. 2006 Aug;113(8):1327-32. Epub 2006 Jun 27.


Created: 04/24/2007
Updated: 04/25/2007