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Ann. psychophysiol. 
ISSN 2412-3188 (Online)|2410-1354 (Print) 

APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v9.i1.2022.51-55 
 

 
Review Article 

Review of Heart Rate Variability 
Biofeedback: Intervention to relieve Stress 
S. Farah Batool1  & Basit Ansari2  

1Department of Psychology, Malir University of Science and Technology, Karachi-Pakistan. 
2Department of Health, Physical Education & Sports Sciences, University of Karachi,  
  Karachi-Pakistan. 
 

Abstract 
Depression is prevailing and captivating millions of individuals across the globe. 
There are numerous stressors and triggers that can induce depressive symptoms 
or anxiety in individuals of all ages. This exponential growth in depressed and 
distressed members of society may lead to a massive loss of productive 
individuals. It is a general practice to prescribe drugs to treat such psychological 
concerns, but acquiring these medications frequently may affect the body's 
metabolism. Alternative interventions that can replace or minimize the use of 
drugs are needed. Heart rate variability biofeedback (HRVB) is a practical 
approach to treating stress and depression. This article intends to represent an 
overview of HRVB, its effectiveness, and its side effects so that it can be compared 
to the medications prescribed. 
 

Keywords 
Heart rate variability, Biofeedback, Stress, Depression. 

 

 

 

 

 

 

 

 

 

 

 

 

Citation: Batool S F, Ansari B. Review of 
Heart Rate Variability Biofeedback: 
Intervention to relieve Stress. APP. 2022; 
9(1): 51-55 
 
Corresponding Author Email: 
farahbatool97@gmail.com 
 
DOI: 10.29052/2412-3188.v9.i1.2022.51-55 
 
Received 25/03/2022 
 
Accepted 10/05/2022 
 
Published 01/06/2022 
 
Copyright © The Author(s). 2022. This is 
an open-access article distributed under 
the terms of the Creative Commons 
Attribution 4.0 International License, 
which permits unrestricted use, 
distribution, and reproduction in any 
medium, provided the original author and 
source are credited.  
 

 

Funding: The author(s) received no 
specific funding for this work. 

Conflicts of Interests: The authors have 
declared that no competing interests 
exist. 
 

https://doi.org/10.29052/2412-3188.v9.i1.2022.51
https://orcid.org/0000-0002-1344-6795
https://orcid.org/0000-0003-3919-2516
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52 

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APP| Published By AEIRC| Volume 9 Issue 1 
 

 

 

Introduction  
World Health Organization has stated that 
depression is among the most prevalent 
psychological concern, afflicting around 265 
million individuals of different age groups 
worldwide1. Mood disorder, decreased 
interest, sleep disruption, diminished desire 
to eat, decelerated thinking, and dearth of 
vitality have all been regarded as possible 
factors associated with the onset and tenacity 
of many other illnesses: people experiencing 
depression seem to be more likely to have 
addiction issues, personality issues, or other 
psychiatric conditions like distress, and 
anxious behavior2,3. People with chronic 
illnesses were more likely to exhibit 
comorbidities with depression, according to 
a global study involving 245,404 persons 
from 60 nations4. Furthermore, depressed 
symptoms are frequently linked to poor 
health outcomes and resistance to drugs and 
therapies. They are frequently coexisting 
with severe health concerns such as type 2 
diabetes, absenteeism, and senile dementia5-

7. Anxiety and depression are also linked to 
an increased risk of heart problems. People 
with cardiovascular disorders are likelier to 
have concomitant depression 8-10. 
 
Heart rate variability (HRV), an assessment 
of the change in the time between every 
pulse, is a critical sign of the function of the 
autonomous nervous system and a powerful 
determinant of clinical incidence and death. 
Higher variability shows the autonomic 
nervous system's capacity for self-
regulation. Because more serious 
complications are strongly related to 
decreased HRV and decreased HRV itself 
appears to be associated with the likelihood 
of incidence of depression, this measure 
could be employed as a prognostic and 
predictive biomarker of distress and 
anxiety11-13. 
 

HRV research led to the development of 
HRV Biofeedback (HRVB), a non-invasive 
therapeutic method aimed at enhancing 
heart rate oscillations through real-time 
feedback and slow breathing exercises13. 
This approach was formulated to solve 
difficulties with HRV regulation discovered 
while treating depression. Prior studies have 
shown that HRVB enhances HRV as 
evaluated by SDNN (the standard deviation 
of NN intervals), high-frequency power 
(HF), and the low-frequency power/high-
frequency power ratio (LF/HF). Each of 
these biological markers has been linked to 
reduced depressed symptoms14.  
 
Heart rate variability biofeedback (HRVB) 
has received much attention in recent 
decades for treating various diseases and 
enhancing productivity. Because asthmatic 
and digestive problems appear to adapt to 
this type of cardio-respiratory feedback 
exercise, the question of plausible causes 
becomes more pertinent. The most widely 
accepted way is that the homeostasis of the 
baroreceptor is strengthened15.  
 
In the 1990s, researchers experimented with 
a type of cardio-respiratory therapy known 
as HRVB. HRV has a complicated structure 
that is sometimes considered "unstable," 
containing multiple overlapping oscillation 
frequencies that are non-linearly connected. 
Some of the activities in this pattern are 
triggered by pre-defined reflexes, while 
others have a modulatory function and are 
influenced by other autonomic pathways16. 
Negative feedback loops help preserve 
allostatic stability while permitting 
sensitivity to external needs. The magnitude 
of heart rate oscillations increases to several 
times at rest during HRV biofeedback, while 
the waveform becomes simple and 
sinusoidal. This trend is observed in 
practically everybody and is often achieved 



 
 

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in a brief moment, even in those who have 
never been subjected to the procedure 
before15,16.  
 
HRVB has been shown in multiple studies to 
reduce physical and psychological 
symptoms while enhancing wellbeing17. In 
an arbitrary meta-analysis investigating the 
efficacy of HRVB on psychological distress 
symptoms, Goessl et al.18. discovered that 
HRVB is a beneficial and effective strategy 
for reducing anxiety and stress. Lehrer et al. 
published a systematic and meta-analytic 
review on the effectiveness of HRVB and/or 
paced breathing on a variety of 
psychological signs and symptoms, 
cognitive functioning, and intricate 
behavioral patterns. HRVB and timed 
breathing had a minor but substantial 
influence on depression, according to the 
researchers19.  
 
Factors related to HRV 
Respiratory Sinus Arrhythmia 
Respiratory Sinus Arrhythmia (RSA) is a 
change in heart rate (HR) due to ventilation, 
with HR rising while inspiration and falling 
with expiration. It plays a key role in 
managing to breathe, ensuring that the 
volume of blood going to the lungs is 
maximal when the lungs have the most 
oxygen. This link is critical for respiratory 
illness and physical and psychological 
performance that necessitates more oxygen 
to the working body and brain. Gaseous 
exchange efficiency is highest when 
ventilation and heart rate oscillations are 
completely in synchrony20. 
 
The neuronal control of RSA seems to be 
another significant component of 
psychological concerns and neuroscience. 
The vagus nerve mediates this neuronal 
control, a key autonomic nerve activated 
during tranquil and relaxing times and 
inhibited during stressful times. The 
magnitude of peak-to-trough heart rate 

fluctuations that occur with every breath can 
be used to calculate the quantity of RSA. 
Healthy people have a higher range of 
changes (in beats per minute) than 
individuals suffering from diseases. Young 
people have a better amplitude of changes, 
and those with optimal aerobic capacity 
have a larger amplitude of changes. It is 
lower in stress, wrath, and despair, as well as 
a variety of physical illnesses, from 
cardiovascular disease to infections20. 
 
The Baroreflex 
The baroreflex is another modulatory reflex 
strongly enhanced by HRVB (BR). The BR 
establishes the circumstances for resonant 
consequences of breathing which result in 
substantial RSA variations. It perceives 
blood pressure fluctuations using stretch 
receptors in the carotid artery and aorta.   
When baroreceptors detect a rise in BP, the 
BRs trigger an immediate decline in HR, 
followed by a physical decline in BP due to 
less blood flows through the vascular 
system21. 
 
Why HRV Biofeedback? 
HRVB promotes a variety of homeostatic 
'negative feedback loops' explicitly. Because 
HRVB stimulates both the baroreflex and the 
RSA, as well as increases parasympathetic 
activity, there is the possibility that HRVB 
will help with emotional control. There are 
grounds to assume that HRVB enhances 
gaseous exchange capabilities that help 
manage respiratory disease and other 
breathing problems due to the obvious in-
phase interaction between breathing and 
heart rate. There are grounds to think it helps 
manage blood pressure as it activates the BR. 
It's possible that stimulating the vagus nerve 
will result in the sense of calm and well-
being19,22. The bolstering of conceptual and 
physiological underpinnings over the past 
few years has helped clarify the connections 
between the brain and the heart that Claude 
Bernard proposed over 150 years ago. 



 
 

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Autonomic regulation of the circulatory 
system and cerebral arousal interact with 
one another. Therefore, changing one will 
impact the other, which could last for a 
while23. More recently, advantages have 
been observed in patients with acute stress 
disorder, urging those under stress to 
employ HRV-BFB training to enhance their 
health, well-being, or competence.  
 
The effectiveness of HRVB with wearable 
technology on self-reported stress is 
confirmed by a recent meta-analysis from 
Goessl et al.24. However, due to a dearth of 
studies in this area, only eight studies 
examined signs of stress as an end parameter 
for healthy persons. In their evaluation of the 
effectiveness of general biofeedback training 
on psychophysiological outcomes of stress, 
De Witte et al.25 underline the need for 
additional research that takes into account 
both psychological and physiological 
characteristics of stress. 
 
It is worth noting that HRV biofeedback is 
not a measurement tool to observe breathing 
rate. Rather it is an intervention in which the 
subject learns to control and optimize 
breathing patterns and heart rate 
variability26. 
 
Possible Side Effects of HRV Biofeedback 
HRVB's distinctive effects have piqued 
interest, maybe as a result of these impacts. 
Each year, the number of HRVB research 
published has increased significantly. It's 
crucial to explain HRVB's potential negative 
effects. In most cases, these are minor 
quibbles. When people initially start slow 
breathing, it's usual for them to 
hyperventilate slightly as the increased 
depth of breathing adapts to the slower 
speed. The apprentice is especially told to 
inhale at a low pace in the conventional 
protocol, particularly in response to 
drowsiness symptoms, which are frequently 
the first hyperventilation symptoms to 

appear. Another potential negative effect 
arises in those who have recurrent cardiac 
arrhythmias19.   
 

Conclusion 
Alternate medicine is a futuristic approach, 

and it is for the benefit of mankind. We, as 

living beings, are vulnerable to psychosocial 

stresses and other linked comorbidities. And 

prefer taking medications for all the issues 

and concerns. Heart rate variability is a great 

alternative and an effective intervention to 

cope with stress and depressive symptoms. 

Trained and certified clinical professionals 

are needed to turn the tables upside down.  

 

Acknowledgment  
I am grateful for the encouragement and 
guidance by my mentors and teachers. Also 
I would like to acknowledge all the authors 
whose work I cited.  
 

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