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Álvaro Avezum, MD, PhD, FESC, FACC

33 o Congresso de Cardiologia SOCERJ- 2016 Conceitos Básicos em Medicina e Espiritualidade. Conceitos de Espiritualidade para atender demandas e prioridades de pacientes e médicos. Álvaro Avezum, MD, PhD, FESC, FACC

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Álvaro Avezum, MD, PhD, FESC, FACC

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  1. 33o Congresso de Cardiologia SOCERJ- 2016 Conceitos Básicos em Medicina e Espiritualidade Conceitos de Espiritualidadeparaatenderdemandas e prioridades de pacientes e médicos Álvaro Avezum, MD, PhD, FESC, FACC Diretor, Divisão de Pesquisa Instituto Dante Pazzanese de Cardiologia Professor Pleno, Programa de Pós-Graduação, IDPC/USP Pesquisador Associado, Population Health Research Institute, McMaster University, Canada

  2. SignificadosparaDemanda • Ato ou efeito de demandar. • Ação de procurar. • Processo judicial destinada a reclamar um direito. • Quantidade de um bem ou de um serviço que o mercado ou um conjunto de consumidores quer comprar, por oposição à oferta. • Disputa, debate. • Pergunta. • em demanda de:  à procura de.

  3. SignificadosparaPrioridade • Anterioridade. • Preferência conferida a alguém, relativamente ao tempo de realização do seu direito, com preterição do de outros.

  4. Nuances duranteConsultaMédica • Masculino, 56a, HAS estágio 1, obesidade, LDL-c: 126mg/dL, (IAM: causa do evento de acordo com paciente sociedade com irmão) • Feminino, 52a, HAS estágio 1 (esofagite com correção cirúrgica de hérnia de hiato, Doença de Crohnileal, artrite a/e e síncopes há 2 anos) [traição conjugal há 2 anos, com paciente dizendo que não consegue perdoar]. • Feminino, 65ª, HAS estágio 2, Obesidade abdominal, LDL-c: 142 mg/dL (SCA-SEST, ICP-DES Da, reestenose intra-stent por 2 vezes com nova ICP e 7 cinecoronariografias em 18 meses) [quebra de confiança em relação ao cônjuge 30 dias antes da SCA-SEST]

  5. DefiniçõesÚteis • Perdão:Remissão de culpa, dívida ou pena; Absolvição, indulto; Benevolência, indulgência; Fórmula que exprime um pedido de desculpas . • Compreensão:Entender; Alcançar com a inteligência; Perceber; Saber apreciar. • Tolerância:Condescendência ou indulgência para com aquilo que não se quer ou não se pode impedir; Boa disposição dos que ouvem com paciência opiniões opostas às suas; Faculdade ou aptidão para suportar. • Paciência:Capacidade de tolerar contrariedades, dissabores, infelicidades; Sossego com que se espera uma coisa desejada; Perseverança; Designativa de resignação, conformidade (paciência de Job =  paciência de santo). • Altruísmo:Inclinação para procurarmos obter o bem para o próximo. • Gratidão: Reconhecimento (por bem que se nos fez). • Resiliência: Propriedade de um corpo de recuperar a sua forma original após sofrer choque ou deformação; Capacidade de superar, de recuperar de adversidades

  6. DefiniçõesÚteis • Mágoa:pesar, ofensa. • Ressentimento:Lembrança magoada de ofensa recebida, mágoa com desejo de reparação ou de vingança. • Vingança:Atitude de quem se sente ofendido ou lesado por outrem e efetua contra ele uma ação mais ou menos equivalente. • Intolerância:Falta de condescendência ou indulgência para com aquilo que não se quer ou não se pode impedir; Falta de boa disposição dos que ouvem com paciência opiniões opostas às suas; Ausência de faculdade ou aptidão para suportar. • Egoísmo:Amor exclusivo à pessoa e aos interesses próprios.

  7. Definições Úteis Rev Bras Clin Med 2010;8:154-8

  8. Definition of Spirituality: ‘‘Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.’’ — p. 646 of Puchalski, C. M., et al., "Improving the Spiritual Dimension of Whole Person Care: Reaching National and International Consensus," Journal of Palliative Medicine 17, no. 6 (June 2014): 642-656

  9. GEMCA-SBC Grupo de Estudos em Espiritualidade e Medicina CArdiovascular da Sociedade Brasileira de Cardiologia

  10. Espiritualidade Estado mental e emocional, que norteia nossos pensamentos, atitudes, ações e reações nas circunstâncias da vida de relacionamento intra e interpessoal. [motivado ou não pela vontade, passível de observação e de mensuração]

  11. INTERHEART: Risco de IAM associado com Fatores de Risconapopulação global (52 países) Yusuf S, Hawken S, Ôunpuu S, Dans T, Avezum A. Lancet 2004 Sept 11

  12. InterHeart América LatinaFR associados com IAM (Impacto Clínico - RAP) Lanas F, Avezum A, Bautista L, Yusuf S, et al. Circulation 2007;115:1067-1074

  13. Risk Factors for All Stroke (All Regions) Risk Factor Control (%) Ischemic (%) ICH (%) OR (99% CI) PAR (99% CI) Hypertension 41.1 65.6 77.1 2.89 (2.61-3.21) 45 (42 - 48.1) Current Smoker 22.2 30.7 29.2 1.80 (1.58-2.06) 13.4 (11.1 - 16) Waist-to-Hip Ratio (T3 vs T1) 32.9 40.2 33.1 1.38 (1.20-1.59) 13.1 (7.6 - 21.7) Diet Risk Score (T3 vs T1) 30.8 44.0 44.5 2.37 (2.08-2.70) 36.6 (31.7 - 41.7) Physical Activity 83.6 88.9 92.0 1.57 (1.33-1.85) 33 (23.9 - 43.6) Diabetes Mellitus 16.5 25.1 13.0 1.09 (0.97-1.24) 2.1 (0.6 - 7.6) High Alcohol Intake 6.6 10.5 9.5 1.56 (1.29-1.90) 3.7 (1.2 - 10.5) Cardiac causes 4.9 16.4 4.4 2.95 (2.45-3.55) 9.5 (8.3 - 11) Psychosocial 1.90 (1.49-2.41) 18.2 (13.5 - 23.9) ApoB/ApoA1 (T3 vs T1) 30.0 43.5 37.1 1.98 (1.74-2.25) 28.8 (24 - 34.1) 0.25 0.5 1 2 4 8 Odds ratio (99% CI) Overall PAR 90.2% (88.0-92.1) Preliminary unpublished results. Not for distribution

  14. Potential pathways by which psychosocial factors influence CHD etiology • Health-related behaviors • Smoking • Diet • Alcohol • Physical activity Stress factors External stressors (life events, financial troubles, high work pace) Internal stressors (perception, coping, anxiety, depression) Clinical CHD Protective factors (income, education, high locus of control Direct pathophysiological mechanisms

  15. Resiliency in the Face of Disadvantage

  16. DASI= Duke Activity Status Index; GQ-6= Gratitude Questionnaire Six Item Form; HADS-A= Hospital Anxiety and Depression Scale—Anxiety Subscale; LOT-R = Life Orientation Test-Revised; MOS-SAS = Medical Outcomes Study Specific Adherence Scale; PAR = Physical activity recall; PHQ-9 = Patient Health Questionnaire-9; SF-12 = Short Form 12; WISE =Women's Ischemia Symptom Evaluation Scale. Contemporary Clinical Trials 44 (2015) 11–19

  17. Quando começamos a adoecer? Uma proposta a ser investigada • Deflagrado o processo de desajuste das energias sutis emocionais/mentais/espirituais criam-se zonas de eleição ou áreas de predisposição mórbida (não há acaso ou sorte; tudo que nos sucede tem uma razão de ser – causalidade [causa e efeito]); • Toda enfermidade nasce das profundezas da consciência/mente/espírito a partir do mente/consciência, atingindo o corpo físico: alteração de funções/manifestação da doença; • Antecedendo as lesões anatomopatológicas, estão as disfunções mais ou menos intensas nos tecidos do corpo espiritual/mental/emocional que têm origem na mente enferma (não há cura sem mudança no panorama interior da criatura); • Antes das alterações patológicas dos tecidos e órgãos: métodos diagnósticos de distonias do corpo espiritual/mental/emocional, antecipando em horas, dias, semanas, meses ou anos a manifestação mórbida na contraparte física;

  18. The effects of a forgiveness intervention on patients with CAD Abstract This research assesses the effects of a psychology of forgiveness pilot study on anger-recall stress induced changes in myocardial perfusion, forgiveness and related variables. Thirty-two patients were administered baseline rest and anger-recall stress imaging studies, and 17 of these participants who demonstrated anger-recall stress induced myocardial perfusion defects (forgiveness group, n = 9; control group, n = 8) were randomly assigned to a series of 10 weekly interpersonal forgiveness or control therapy sessions with a trained psychologist, and underwent additional anger-recall stress myocardial perfusion nuclear imaging studies post-test and at 10-week follow-up. Patients assigned to the forgiveness group showed significantly fewer anger-recall induced myocardial perfusion defects from pre-test to the 10-week follow-up as well as significantly greater gains in forgiveness from pre-test to post-test and from pre-test to follow-up compared to the control group. Forgiveness intervention may be an effective means of reducing anger-induced myocardial ischemia in patients with coronary artery disease. Psychol Health. 2009 Jan;24(1):11-27.

  19. Effect of anger and trait forgiveness on cardiovascular risk in young adult females Abstract High trait anger is linked to adverse cardiovascular outcomes. A potential antidote to the cardiotoxic influence of anger is trait forgiveness (TF), as it has shown associations with improved blood pressure (BP) and cardiovagal tone regulation in cardiac patients. However, it has yet to be determined if anger and forgiveness independently predict cardiovascular parameters. Trait anger (State-Trait Anger Expression Inventory-2) and TF (Tendency to Forgive Scale) were evaluated in 308 (M = 21.11years ± SD = 2.52) healthy female volunteers allocated to 3 related, yet distinct, studies. Hierarchical multiple regressions tested the incremental contribution of TF after accounting for anger. Study 1 assessed autonomic modulation through beat-to-beat BP and spectral analysis to examine sympathovagal balance and baroreflex functioning. Study 2 used tonometry and pulse wave analysis for aortic hemodynamics. Study 3 assessed 24-hour ambulatory BP and ambulatory arterial stiffness index. Hierarchical models demonstrated that anger was significantly associated with increased sympathovagal tone, increased hemodynamic indices, high ambulatory BPs, and attenuated BP variability and baroreflex. In contrast, TF was associated with more favorable hemodynamic effects (i.e., decreased ventricular work and myocardial oxygen consumption). In conclusion, these results demonstrate divergent cardiovascular effects of anger and forgiveness, such that anger is associated with a more cardiotoxic autonomic and hemodynamic profile, whereas TF is associated with a more cardioprotective profile. These findings suggest that interventions aimed at decreasing anger while increasing forgiveness may be clinically relevant. Am J Cardiol. 2014 Jul 1;114(1):47-52.

  20. Relationship between forgiveness and psychological and physiological indices in cardiac pts Int J Behav Med. 2009;16(3):205-11. BACKGROUND: Research suggests that forgiveness is associated with better psychological and physical health and in particular cardiovascular functioning. PURPOSE: The current study assessed the psychological and physiological correlates of forgiveness in individuals with coronary artery disease (CAD). METHOD: Self-reported forgiveness, perceived stress, anxiety, and depression, and physiological data, including triglycerides, total cholesterol, high- (HDL) and low-density lipoprotein (LDL) cholesterol, were obtained from 85 hospitalized CAD patients. RESULTS: Higher levels of forgiveness were associated with lower levels of anxiety (p < 0.05), depression (p < 0.01), and perceived stress (p < 0.005) as well as lower total cholesterol to HDL and LDL to HDL ratios (both at p < 0.05) after controlling for age and gender. The psychological indices did not mediate the relationship between forgiveness and cholesterol ratios. CONCLUSIONS: Results suggest that the psychological correlates of forgiveness are similar in cardiac patients and healthy individuals. Further, among cardiac patients, forgiveness may be associated with reduced risk for future cardiovascular events.

  21. Trait anger but not anxiety predicts incident T2DM: The Multi-Ethnic Study of Atherosclerosis (MESA). Psychoneuroendocrinology. 2015 Oct;60:105-13. OBJECTIVE: Prior studies have shown a bidirectional association between depression and T2DM; however, the prospective associations of anger and anxiety with T2DM have not been established. We hypothesized that trait anger and anxiety would predict incident T2DM, independently of depressive symptoms. RESEARCH DESIGN AND METHODS: In the Multi-ethnic Study of Atherosclerosis, we prospectively examined the association of trait anger and trait anxiety (assessed via the Spielberger Trait Anger and Anxiety Scales, respectively) with incident T2DM over 11.4 years in 5598 White, Black, Hispanic, and Chinese participants (53.2% women, mean age 61.6 years) at baseline without prevalent T2DM or CVD. We used Cox proportional hazards models to calculate the hazard ratios (HR) of incident T2DM by previously defined anger category (low, moderate, high), and anxiety quartile, as there were no previously defined categories. RESULTS: High total trait anger was associated with incident T2DM (HR 1.50; 95% CI 1.08-2.07) relative to low total trait anger. The association was attenuated following adjustment for waist circumference (HR 1.32; 95% CI 0.94-1.86). Higher anger reaction was also associated with incident T2DM (HR=1.07; 95% CI 1.03- 1.11) that remained significant after adjusting for potential confounders/explanatory factors. In contrast, trait anxiety did not predict incident T2DM. CONCLUSIONS: High total trait anger and anger reaction are potential modifiable risk factors for T2DM. Further research is needed to explore the mechanisms of the anger-diabetes relationship and to develop preventive interventions.

  22. Anger proneness, gender, and the risk of heart failure. J Card Fail. 2014 Dec;20(12):1020-6 Evidence regarding the association of anger proneness with incidence of heart failure is lacking. METHODS AND RESULTS: Anger proneness was ascertained among 13,171 black and white participants of the ARIC study cohort with the use of the Spielberger Trait Anger Scale. Incident heart failure events, defined as occurrence of ICD-9-CM code 428.x, were ascertained from participants' medical records during follow-up in the years 1990-2010. Relative hazard of heart failure across categories of trait anger was estimated with the use of Cox proportional hazard models. Study participants (mean age 56.9 [SD 5.7] years) experienced 1,985 incident HF events during 18.5 (SD 4.9) years of follow-up. Incidence of HF was greater among those with high, as compared to those with low or moderate trait anger, with higher incidence observed for men than for women. The relative hazard of incident HF was modestly high among those with high trait anger, compared with those with low or moderate trait anger (age-adjusted hazard ratio for men: 1.44 (95% confidence interval [CI] 1.23-1.69). Adjustment for comorbidities and depressive symptoms attenuated the estimated age-adjusted relative hazard in men to 1.26 (95% CI 1.00-1.60). CONCLUSIONS: Assessment of anger proneness may be necessary in successful prevention and clinical management of heart failure, especially in men.

  23. Lifestyle medicine: the future of chronic disease management. Curr Opin Endocrinol Diabetes Obes. 2013 Oct;20(5):389-95. PURPOSE OF REVIEW: Lifestyle medicine is a new discipline that has recently emerged as a systematized approach for management of chronic disease. The practice of lifestyle medicine requires skills and competency in addressing multiple health risk behaviours and improving self-management. Targets include diet, physical activity, behaviour change, body weight control, treatment plan adherence, stress and coping, spirituality, mind body techniques, tobacco and substance abuse. This review focuses on the impact of a healthy lifestyle on chronic disease, the rarity of good health and the challenges of implementing a lifestyle medicine programme. RECENT FINDINGS: Unhealthy lifestyle behaviours are at the root of the global burden of noncommunicable diseases and account for about 63% of all deaths. Over the past several years, there has been an increased interest in evaluating the benefit of adhering to 'low-risk lifestyle' behaviours and ideal 'cardiovascular health metrics'. Although a healthy lifestyle has repeatedly been shown to improve mortality, the population prevalence of healthy living remains low. SUMMARY: Lifestyle medicine presents a new and challenging approach to address the prevention and treatment of noncommunicable diseases, the most important and prevalent causes for increased morbidity and mortality worldwide.

  24. Áreas de Pesquisa • Estratégias transversais • Avaliação de espiritualidade e de religiosidade por meio de escalas validadas no Brasil: • em pacientes portadores de doença arterial coronária (clínico/ICP/RM) • em pacientes portadores de SCA • em cardiologistas associados à Sociedade Brasileira de Cardiologia • na população brasileira • Validação de novas escalas avaliando fatores de enfrentamento positivo e negativo com DCV (perdão, solidariedade, “fazer o bem”) em população com DCV

  25. Estudos casos-controles • Associação de espiritualidade e de religiosidade: • com infarto agudo do miocárdio (síndromes coronárias agudas) • com Doença Arterial Coronária • com Insuficiência Cardíaca • com Hipertensão Arterial Sistêmica • com Fibrilação Atrial • com Acidente Vascular Cerebral • com Dislipidemia

  26. Estudos de coorte prospectivos • Inclusão de escalas de espiritualidade e de religiosidade no estudo prospectivo internacional PURE • Inclusão de escalas de espiritualidade e de religiosidade no estudo prospectivo ELSI (Projeto Veranópolis) • Inclusão de escalas de espiritualidade e de religiosidade no estudo prospectivo ELSI - Internacional

  27. Estudos clínicos randomizados • Intervenção Baseada em Espiritualidade em pacientes com Síndromes Coronárias Agudas (seguimento 1 ano, desfechos clinicamente relevantes) • Intervenção Baseada em Espiritualidade em pacientes com Doença Arterial Coronária (seguimento 4 anos, desfechos clinicamente relevantes)

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