Abstract Body (Do not enter title and authors here): Background:
Yoga is associated with improved cardiovascular risk factors, but its impact on major adverse cardiac events remains uncertain. We evaluated whether regular yoga practice is associated with a reduced incidence of acute coronary syndrome (ACS) in hypertensive adults using real-world data.

Methods:
We conducted a retrospective cohort study using the TriNetX research network. Adults aged ≥18 with ≥2 hypertension-related diagnoses were included. Cohort A (yoga group) comprised patients with ≥2 yoga-related encounters within a 1-month period. Cohort B (control group) included hypertensive adults with no documented yoga exposure. Patients with prior ACS were excluded. Propensity score matching (1:1) was performed based on age, sex, smoking history (F17., Z72.0), and type 2 diabetes (E11.), yielding 1,269,231 patients per group. The primary outcome was incident ACS (ICD-10: I20.0–I23.*) within 3 years after index. Secondary outcomes included all-cause mortality, stroke/transient ischemic attack (TIA), and cardiac arrest. Outcomes were assessed using risk ratios (RR), hazard ratios (HR), and Kaplan-Meier survival.

Results:
Over 3 years, ACS occurred in 0.6% of the yoga group (n=7,317) vs. 2.0% of the non-yoga group (n=25,672), corresponding to an absolute risk reduction of 1.4%, RR of 0.30 (95% CI: 0.29–0.31), and HR of 0.41 (95% CI: 0.40–0.42; p<0.0001). The number needed to treat (NNT) was 71. Kaplan-Meier curves showed early and sustained divergence in ACS-free survival beginning at 6 months. Stroke/TIA occurred in 2.1% of yoga patients vs. 5.2% in controls (RR: 0.40; HR: 0.54; p<0.0001). Cardiac arrest occurred in 0.6% vs. 0.9%, respectively (RR: 0.66; HR: 0.88; p<0.0001). All-cause mortality was higher in the yoga group (12.0% vs. 6.9%, HR: 2.29; p<0.0001), potentially reflecting residual confounding, reverse causation, or inclusion of nonspecific counseling codes such as Z71.89.

Conclusion:
In this large, matched real-world cohort, regular yoga practice was associated with a significantly reduced risk of ACS, stroke/TIA, and cardiac arrest among hypertensive adults. These findings support yoga as a complementary strategy in cardiovascular prevention. Further investigation is warranted to clarify unexpected mortality trend.