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 9.3. Primary Prevention Available scientific evidence describes that high levels of spirituality and religiosity are associated with lower prevalence of smoking, alcohol consumption, sedentarism/PA, better nutritional and pharmacological adherence in dyslipidemia, hypertension, obesity and DM. 365,399-401 Alcohol: In many studies that examined the relationship between spirituality and religiosity with alcohol use, an inverse relationship was found; that is, there were higher rates of spirituality or frequency of religious activity, with lower alcohol consumption. According to the same authors, several studies have shown that more religious individuals are more physically active. There is also a positive relationship between spirituality and religiosity and PA. 365 Among Brazilian university students, a higher prevalence of alcohol consumption, smoking and use of at least one illicit drug in the last 30 days among those who had less frequent religious involvement. 399 Smoking: In the CARDIA cohort study, it was observed that religiosity was related to lower risk of subclinical carotid atherosclerosis and had a positive association with higher consumption of fiber, vegetables and fruits, and lower consumption of processed foods. 401,402 Obesity: In both the MESA and CARDIA studies, a higher association was observed between extent of religious involvement and higher propensity for obesity. 401,402 Compared to those who did not participate in any religious activity, individuals with different frequencies of religious involvement were significantly more prone to obesity even after adjusting for demographic and smoking characteristics. Diabetes mellitus: Regarding diabetes, although they are more prone to obesity, patients with greater religiosity had no higher risk of being diabetic. This may be explained by better diet or better treatment adherence. 366 In contrast, in the Third National Health and Nutrition Examination Survey (NHANES III) study, there was no association between diabetes and attendance at religious services. 370 Hypertension: Regarding hypertension, the results are contradictory. In the Chicago Community Adult Health Study, it was found that higher religiosity indicators were not associated with hypertension. 403 In the prospective Black Women’s Health Study, after an 8-year follow-up, the greater involvement with spirituality and religiosity employed in coping with stressful events was associated with a lower risk of developing hypertension, especially in women with higher stress. 404 A national study involving a highly religious community found that the prevalence of hypertension among these individuals was lower than the national prevalence. 405 Meditation is one of the most studied interventions among practices related to spirituality and religiosity and the repercussions on BP levels. In these studies, the magnitude of BP reduction varies significantly. Studies have methodological limitations with data bias, high dropout rates, and different populations studied. In a systematic literature review, transcendental meditation reduced SBP by ~4 mmHg and DBP by ~2 mmHg, effects comparable to other lifestyle interventions such as weight loss and exercise. 407 The mechanisms by which meditation reduces PA have not yet been fully elucidated. Possibly, the long-term neurophysiological changes that occur with meditation may lead to changes mediated by the autonomic nervous system in BP. The impact of stress reduction on BP remains to be better defined. 406 9.4. Secondary Prevention As with primary prevention, secondary prevention should be viewed as comprehensive and taking into account psychosocial factors such as socioeconomic status, depression, anxiety, hostility/anger, and type D personality that may aggravate CVD. 2 In this context, some of these factors should be highlighted, as well as the results obtained with new proposals for intervention in the field of spirituality, religiosity and related areas. Forgiveness: Evaluated by various scales as tendency and attitude, forgiveness determines multiple effects, generating states more favorable to homeostasis in the emotional, cognitive, physiological, psychological, and spiritual aspects. Forgiveness broadens the possibilities for behavior by building better adaptive strategies and counteracting the feelings of anxiety, anger, and hostility that are potent CV risk factors. It also reduces stress, drug addiction and rumination; improves social support, interpersonal relationships, and health self-care. 409-413 One study analyzed the effect of forgiveness on myocardial ischemia, ischemia generated by stress and measured by scintigraphy techniques. Patients were randomized to receive or not a series of psychotherapy sessions to develop interpersonal forgiveness. After 10 weeks of follow-up, the forgiveness intervention was able to reduce the burden of anger-induced myocardial ischemia in patients with CAD. 414 Gratitude: In clinical practice, gratitude can be assessed by specific questionnaires such as the Gratitude Questionnaire – 6 (GQ-6), 415 allowing the analysis of behavioral interactions and physiological, pathophysiological and clinical outcomes. Individuals with greater gratitude have a better CV health profile, similarly to those with higher spirituality and religiosity indices. In asymptomatic HF patients assessed by the gratitude, depression, sleep, gratitude, and spiritual well-being questionnaires, the latter two correlated with better inflammatory profile and better mood and sleep quality, less fatigue, and greater self-efficacy. 416 Psychological strategies that may increase feelings of gratitude such as regular journaling, thoughts, meditation, and fact-checking, or grateful people have been studied, demonstrating increased feelings of gratitude and reduced inflammatory markers. 417 Depression and Resilience: Depression is significantly more common in patients with CVD than in the general community. This higher prevalence is often secondary to the disease as an adaptation disorder, with symptoms disappearing spontaneously in most patients. However, approximately 15% of them develop a major depressive disorder, which is an independent risk marker of increased morbidity and mortality. 418,419 In a cross-sectional study including 133 patients diagnosed with ischemic heart disease assessed by the Wagnild & Young Resilience Scale, 81% were classified as 838