ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 exercise may be included in the prescription, such as motor coordination and balance exercises, not tomention the numerous opportunities generated by more playful forms and exercise socializers such as ballroom dancing and Tai-Chi-Chuan. 351,352 Performing assessments of aerobic and non-aerobic fitness allows a more individualized prescription of physical exercise, aiming to obtain the best results and, through risk stratification and search for hidden abnormalities, minimize the risks of exercise of any kind or intensity. The initial evaluation consists of anamnesis, physical examination and ECG. More detailed assessments should be individualized, with exercise testing or maximal exercise cardiopulmonary testing, anthropometric assessment, muscle strength/power and flexibility. In the initial evaluation, we can quantify the functional deficit against the desirable, as well as set goals to be achieved. It is important to emphasize that even those with low initial levels of physical fitness can benefit from and become adherent to a supervised exercise program. 353 It is also possible to obtain clinical and functional support for appropriate counseling on sexual activity based on the KiTOMI model proposed by Brazilian authors in 2016. 354 It is essential for commitment to be encouraged in the patient on reevaluation, while measuring his/her evolution and benefits obtained. 8.8. Formal and Informal Physical Activity: Encouraging Referral, Implementation and Adherence Although health benefits occur with relatively low intensity activities resulting from informal daily actions such as walking, climbing stairs, cycling and dancing, it is ideal that regular exercise (formal activities) also occur, which provides greater gains. Patients with heart disease also benefit from regular physical exercise, ideally in the context of a formal CV rehabilitation program (or supervised physical exercise). CV rehabilitation acts on major disease outcomes, with proven effects by meta- analyses of randomized trials, reducing CV mortality, reducing hospitalizations 355,356 and improving quality of life. In addition, CV rehabilitation is a cost-effective treatment. 357,358 A possible way to improve exercise counseling by health professionals would be to combat their physical inactivity, as it has been shown that physically active people have greater knowledge about recommendations on prescribed exercises and can motivate more. 359 In addition to direct medical practice, there is a need for changes in public and private policies, with the need for comprehensive strategies established through simultaneous actions, such as increasing physical activity in school programs; transport policies and systems that favor commuting through walking, cycling and public transportation; public education, including public awareness campaigns; sports organization at various levels (school, work, community etc.), with proposals that encourage and enable lifelong sports, from childhood to old age. 8.9. Final Messages Physical inactivity should be combated by increasing physical activity in its various forms, both structured, physical and unstructured, favoring urban mobility with bicycle paths and facilitating travel through walking. There is a consensus that a good and plausible weekly goal for health promotion and CVD prevention is to engage in physical activity/exercise/sport for at least 150 minutes of moderate intensity or 75 minutes of high intensity. Given the current stage of knowledge, it can be said that: • any amount of physical activity is better than none, and sedentarism is a worse possible situation; • the benefits of exercise seem to be greater with more exercise, up to 5 times the minimum recommendation; • there is no consistent scientific evidence that more than 10 times the minimum recommended exercise is harmful to health; • there are no longitudinal studies relating heart disease to severe physical exercise, when performed regularly in healthy individuals. 303,360 9. Spirituality and Psychosocial Factors in Cardiovascular Medicine 9.1. Concepts, Definitions and Rationale 9.1.1. Introduction There are lines of evidence that demonstrate a strong relationship between spirituality, religion and religiosity and the processes of health, illness and healing, composing together the physical, psychological and social aspects of the integral vision of the human being. In contrast to the easy conceptual assimilation, obstacles are observed, mainly due to lack of knowledge of the concept and scientific outdating, regarding the operationalization of the spirituality construct and the understanding of how to measure and evaluate its influence on health outcomes. 361 Spirituality and religiosity are valuable resources used by patients to cope with illness and suffering. The process of understanding relevance, identifying demands, and providing adequate spiritual and religious support benefits both patients, the multidisciplinary team, and the health system itself. About 80% of the world’s population have some religious affiliation, and faith has been identified as a powerful mobilizing force in the lives of individuals and communities. 362,363 9.1.2. Concepts and Definitions Definitions of spirituality typically merge with other constructs such as religiosity and the dimensions of psychological well-being, especially positive relationships with other people, purpose in life, and sometimes paranormal beliefs. Conceptual heterogeneity has been widely recognized and, for some authors, spirituality has no clear definition, the term being used inaccurately and inconsistently, varying according to religion, culture and time and therefore difficult to gauge. 364 The meaning of the word religion has Latin derivations that refer to rereading (from scripture), to (re) binding or even to 833