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 resilient, suggesting that disease may act as a facilitator for the presence of this feeling. 420 Resilience is a behavior that greatly improves treatment adherence as well as quality of life and can be acquired at any stage of life, regardless of age and disease state. Spirituality and religiosity are associated with higher levels of resilience. 420,421 In another series, elderly patients (≥ 65 years) were significantly more resilient than younger patients. Resilience correlated negatively with depression and inversely with affective, cognitive, and somatic symptoms of depression andwas responsible for greater variation in the affective characteristics of depression than in the somatic characteristics. 419 In a long-term cohort, patients were analyzed for functional social support, BMI, recent history of major depression, coronary artery disease, hypertension, and diabetes. After 13 years, it was observed that social support was responsible for reducing the relationship between depression and the occurrence of coronary artery disease. Specifically, depression was prospectively associated with coronary artery disease among individuals with low social support but not those with high support, suggesting that it may function as a resilience factor against CV risk associated with depression. 422 The Palliative Care in Heart Failure study was the first randomized controlled trial involving palliative care to demonstrate the significant clinical benefit of incorporating interdisciplinary interventions in the management of patients with advanced HF. The addition of palliative care improved physical and psychosocial condition (anxiety/depression), and spiritual quality of life. 423 Relaxation and Meditation: Relaxation and meditation are well-established mind/body approaches to improving stress, and their benefit has been demonstrated in many populations, including heart disease. 344.424-426 Easy to learn and practical, they are inexpensive and widely accessible techniques. In an observational study in patients with coronary artery disease, the cardiac rehabilitation strategy associated with a 13-week program was analyzed using self-relaxation, spiritual well-being and psychological stress control techniques. There were significant increases in relaxation practice time and spiritual well-being scores, as well as improvement in depression, anxiety, hostility, and overall severity scores. A greater increase in relaxation practice time was associated with spiritual well-being, which in turn was associated with improved psychological outcomes. 424 Patients with coronary artery disease were enrolled in a transcendental meditation or health education program with an average follow-up of 5.4 years. Transcendental meditation significantly reduced the risk of mortality, myocardial infarction, and stroke, these changes being associated with lower BP levels and psychosocial stressors. Additionally, a national study randomized patients with chronic HF to do meditation or not, demonstrating a reduction in serum norepinephrine and VE/VCO 2 slope in the cardiopulmonary test and improved quality of life assessed by the Minnesota Living with Heart Failure questionnaire. 426 A recent paper by the American Heart Association reviews various forms of meditation and highlights the prolonged effects observed on brain physiology and anatomy, possibly responsible for better systemic physiological status and reduced cardiovascular risk. Meditation shows a better physiological response to stress, smoking cessation, reduced BP, insulin resistance and metabolic syndrome, endothelial function, inducible myocardial ischemia, and primary and secondary prevention of CVD. Although some data on CVD risk reduction are limited, meditation can be considered as a complement to risk reduction and lifestyle modification. 344 In a robust study involving 1,120 meditators, other complex domains have been identified that may be crucial to people’s psychological and spiritual development by acting as mediators and/or mechanisms responsible for the effects of meditation. Of difficult measurement, relational and transpersonal aspects, mystics, and anomalous or extraordinary phenomena linked to meditation deserve further study. The extent of the possible effects to be obtained with each form of meditation remains open. Transcendental meditation has been shown to reduce anxiety, improve mood, and to double the acute pain tolerance time when compared to secular forms of meditation. 428 Medication adherence: In a cohort of 130 HF patients, adequate adherence score was observed in only 38.5% of patients. Spirituality, religiosity, and personal beliefs were the only variables consistently associated with adherence. It is noteworthy that depression or religiosity were not correlated with adherence when evaluated separately. When spirituality was assessed by both, it was positively correlated with adherence, adjusted for demographic and clinical characteristics and psychosocial instruments. 429 Cardiac Rehabilitation: Several studies report improvement in psychological stress in patients with coronary artery disease undergoing CV rehabilitation. In addition, a meta-analysis of 23 randomized controlled trials involving 3,180 coronary artery disease patients seeking to assess the impact of adding psychosocial interventions to standard rehabilitation exercise reported greater reduction in psychological distress and improvements in SBP and serum cholesterol. 430 The scope of cardiac rehabilitation can be amplified by positive psychology techniques. In patients undergoing coronary angioplasty, these explanatory techniques, with telephone contacts and inductive correspondence, resulted in better physical performance (caloric expenditure), with a reduction in medical events, as opposed to the effects observed by stress. 431 In another meta-analysis, the influence of rehabilitation associated with psychosocial and/or educational interventions in 14,486 individuals with pre-established coronary artery disease with a median follow-up of 12 months was evaluated. In general, rehabilitation led to a reduction in CVD mortality and the risk of hospitalizations and a better quality of life. 354 9.5. Recommendations for Clinical Practice  Most patients and their families, guardians or caregivers have varying degrees of religiosity and spiritual needs and, importantly, expect health professionals to know their beliefs and to be part of the decision-making process, reinforcing the concept of integrality. 839