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 week with no frequency. On the other hand, involvement in prayer several times a day, religious confrontation or self-identification as a very religious/spiritual person did not correlate with mortality. 375 This interface between spirituality and religiosity and health and illness processes is multifactorial and can, in part, be attributed to a behavioral self-regulation determined by religious affiliation and participation, with reduced consumption of alcohol, tobacco and drugs, reduction in the number of partners, better transport, food and access to health care. Emotionally, religious communion brings better positive psychology and social support, and positive spiritual coping can provide more hope, forgiveness, comfort, love, and other benefits. In addition to behavioral aspects, most studies demonstrate the beneficial relationship between spirituality and religiosity and the physiological and pathophysiological variables of many clinical entities, including CVD. Despite the great heterogeneity between studies, better BP levels, neurohormones and autonomic nervous system activation, HR variability, dyslipidemia, CV risk, atherosclerotic disease, DM, CRP and other markers of inflammation and immunity have been observed. 365,368 Another way of understanding the scope spirituality and religiosity may have on clinically relevant outcomes, including greater longevity, is expressed in the direct relationship with telomere size in leukocytes. 376,377 9.2. Spiritual History and Scales for Measuring Religiosity and Spirituality The degree of spirituality and religiosity of patients can be assessed in spiritual history or anamnesis, understood as “the set of questions asked to the patient to share their spiritual and religious values, to identify possible spiritual issues that may contribute to or undermine the therapy, as well as feelings that are used in daily life, in the life of relationship, whether positive (edifying) or negative (not edifying).” It should always be patient-centered and guided by what it expresses about its spirituality. 378 At first, spiritual anamnesis as an integral part of clinical history should be obtained from all patients seeking medical attention, but especially those hospitalized with serious, chronic, progressive or debilitating illness. 9.2.1. Why Address Spirituality and Religiosity The approach to the subject is very important because many patients are religious or spiritual, and their beliefs influence how to cope with adverse situations in life and may help to cope with the disease. During periods of hospitalization or chronic illness, they are often removed from their communities and prevented from practicing their religious beliefs. In addition, personal beliefs may affect health- related decisions that may be conflicting with treatment. 379,380 Many health professionals do not know if patients wish, agree with, or are open to this approach. Studies show that most patients would like their doctors to ask about spirituality and religiosity, generating more empathy and trust in the doctor and thus rescuing the doctor-patient relationship, with a more humane care. 381,382 9.2.2. Objectives of Spirituality and Religiosity Assessment It is essential to seek to understand the patients’ beliefs, identify aspects that interfere with health care, evaluate the individual, family or social spiritual strength that will allow them to cope with the disease, offer empathy and support, help them to find acceptance of the disease and identify situations of conflict or spiritual suffering that will require evaluation by a skilled professional. 383,384 In this evaluation, it is essential to detect negative feelings that may contribute to the illness or aggravation of the condition, such as hurt, resentment, unforgiveness, ingratitude, among others. 9.2.3. How to Address Patient Spirituality and Religiosity There are several ways to approach this issue, and most importantly it should be done sensitively without promoting religion or prescribing prayers or religious practices. Nor should the individual be coerced into adopting specific beliefs or practices. Most of the time, the approach can be taken naturally, during the interview, as the doctor assesses psychosocial aspects. 365 Patients should be asked about the importance of spirituality, religiosity, and religion to them, if this helps to cope with illness, generates stress or negative feelings (guilt, punishment etc.), or influences treatment adherence or decisions, and if there are any unmet spiritual needs. The health professional should be sensitive and welcoming to religious beliefs and practices. If there are negative feelings, conflicts, or spiritual needs, the provider should solicit the participation of a trained individual or member of the patient’s community to properly address these issues. In the case of nonreligious patients or those who refuse to talk about the subject, the doctor may inquire about the ways in which individuals live with the disease, what promotes purpose and meaning for their life (family, friends, hobby etc.) and what beliefs may have an impact on their treatment. For this approach to be non-conflictive, preparation and acceptance by both health professionals and patients is required. 9.2.4. Scales and Instruments for Evaluating Spirituality and Religiosity Measuring spirituality and religiosity in clinical practice and research is challenging, given the complexity of the elements and definitions involved in denomination, beliefs, religious/ spiritual practices, participation in religious communities, support in dealing with illness, forgiveness, gratitude, altruism, spiritual well-being, pain or suffering and others. The various psychometric instruments can be divided into tools for spiritual tracking or for spiritual history collection. 386,387 1. Spiritual Tracking – Evaluate the presence of spiritual needs that indicate deeper assessment. They are brief and easy to apply. Some of the instruments for spiritual tracking are listed in Chart 9.1. Spiritual tracking provides important information and may indicate the need for further evaluation, although aspects remain to be studied (better time to apply in different stages of the disease and differences in cultural context, among others). 835