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 reelection (back to a god), inferring connections to deity, other people, or their beliefs and values. Although the term religion in the past (and in current theological erudition) has been used to grasp the institutional and individual dimensions of experience, contemporary references to religion increasingly imply institutional, social, doctrinal, and denominational characteristics of lived experiences. 361 According to Koenig, religion is “an organized system of beliefs, practices and symbols designed to facilitate closeness with the transcendent or the Divine and foster understanding of one’s relationship and responsibilities with others living in the community”. 361,363-365 Religion is a multidimensional construct that includes beliefs, behaviors, dogmas, rituals and ceremonies that can be practiced in private or public contexts, but are somehow derived from established traditions that have developed over time within a community. Religion is also designed to facilitate closeness with the transcendent and promote an understanding of one’s relationship and responsibility to others when living in a community. 365 Religiosity is how much an individual believes, follows and practices a religion. It can be organizational (church, temple, or religious services) or non-organizational such as praying, reading books, or attending religious programs. Historically, spirituality was considered a process that unfolded within a religious context, with institutions designed to facilitate the spiritualization of the practitioner. Only recently has spirituality been separated from religion as a distinct construct, in part because of the distancing from the authority of religious institutions in modern social life and the increasing emphasis of individualism on Western cultures. 361 More recently, faced with the need to standardize a definition for spirituality in palliative care, a group of interprofessional specialists in palliative and spiritual care has defined spirituality as “a dynamic and intrinsic aspect of humanity, through which people seek meaning, purpose and transcendence and experience relationship with self, family, others, community, society, nature and the meaningful or sacred. Spirituality is expressed through beliefs, values, traditions and practices.” 366 According to the Study Group on Spirituality and Cardiovascular Medicine (GEMCA) of the Brazilian Society of Cardiology, “spirituality is a set of moral, mental and emotional values ​that guide thoughts, behaviors and attitudes in the circumstances of intra- and interpersonal relationship life.” One can also add the aspect of being motivated or not by the will and be subject to observation and measurement (http:// departamentos.cardiol.br/gemca ). We consider it important that spirituality be valued measurable in all individuals, regardless of religious affiliation, including atheists, agnostics, or even those with religious affiliation but without observing and practicing it. For some, both atheists and agnostics, while not believing or uncertain about God’s existence, still have a form of spirituality based on existential philosophy, finding meaning, purpose, and fulfillment in their own lives. Spirituality evokes concerns, compassion, and a sense of connection with something greater than us. 367 Thus, spirituality may include religion and other universal views, but it encompasses much more general ways in which these experiences are expressed, including through the arts, relationships with nature and others, and for some through the concept of “secular humanism.” This emphasizing reason, scientific inquiry, individual freedom and responsibility, human values, compassion and the needs for tolerance and cooperation. 9.1.3. Rationale and Mechanisms A significant and growing body of evidence demonstrates an association between spirituality and religiosity and mortality indices, quality of life, with supposed mechanisms based on a huge range of biological and mediating variables, varying according to the model of healthy populations (or not). -healthy), forms of expression of spirituality and religiosity, research development scenario etc. 365,368,369 In an American cohort predominantly composed of Christians > 40 years of age and followed for an average of 8.5 years, a lower risk of death was observed, regardless of confounding factors among those who reported religious services at least once a week compared to no presence. The association was substantially mediated by health behaviors and other risk factors. 370 In a 2009 systematic review, spirituality/religiosity was associated with reduced mortality in studies involving healthy populations, but not in trials of the sick population. The protective effect of spirituality and religiosity was independent of behavioral factors such as smoking, alcohol, exercise, socioeconomic status, negative affect, and social support. When compared to organizational but not non-organizational religious activities, it was associated with longer survival. 371 In the Women’s Health Initiative study involving more than 43,000 menopausal women, CV risk was highest in patients with private spiritual activity such as prayer, Bible reading, and meditation. Subgroup analysis suggests that this association may be determined by the presence of severe chronic diseases. 372 It is possible that spirituality and religiosity will have little impact on outcomes once disease is established, identified and treated, and is more important in promoting resistance to health problems before they reach an advanced stage. It should also be noted that religious coping is often used but may have positive or negative connotations. Negative religious coping (such as passive acceptance of fatality and requests for direct intercession) can be detrimental in contrast to other beneficial effects. 371 More recently, new cohort studies have made important contributions from the perspective of epidemiology and the associations between religious service, mortality and quality of life. In the Nurses’ Health Study cohort of over 74,000 nurses followed for up to 8 years, both all-cause mortality and CVD or cancer mortality were reduced by about 30% in women who attended religious services at least once a week compared to those without any participation. 373 In this same population, attendance at religious services was significantly associated with lower suicide rate. 374 Similarly, the follow-up of a large cohort of black American women showed a significant 46% reduction in mortality rate, comparing attendance at religious services several times a 834