Do We Need a Better or Expanded Paradigm to Address Residual Risk?

Spirituality has been recognized as an emergent factor for cardiovascular disease, both protector and risk factor. The Updated Guidelines for Cardiovascular Prevention of the Brazilian Society of Cardiology added a chapter including the Spirituality as a factor alongside others traditional factors such as tobacco, hypertension and cholesterol. We are living in a remarkable era with opportunity to utilize consistent medical research data due to researchers are bringing to mainstream a better understanding of pathophysiology and potential therapeutic interventions. This is accomplished through the publication of rigorous scientific research, which has been demonstrated to produce more reliable and robust outcomes. The 2021 Scientific Statement from the American Heart Association published in the journal Circulation state: “we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a Whole.” In addition, the physical aspects of our body to our behavior, dietary and sleep hygiene habits, what else affects our health? How much of our thoughts and feelings interfere in our health? What else are we made of? Are there other aspects impacting our health that we might be overlooking? Do illnesses and physiological processes arise due to the involvement of the body and also the mind/psyche? Our evolving perception of the world extends beyond rational processes to encompass various factors within intra and interpersonal relationships.

We are witnessing significant changes across all aspects of our society, and these changes will inevitably impact the field of medicine. Typically, any change faces resistance, opposition, and even sarcasm before it is eventually accepted. The level of acceptance relies on demonstrating persistent resilience and consistency in pursuing objectives. Without these qualities, no change can overcome the prevailing mainstream, especially among health professionals and doctors.

This year has witnessed a notable surge in the examination of spirituality and religiosity, prompting discussions about its potential incorporation into the medical realm. Three influential publications, namely the European Journal of Cardiology: "Religiosity/Spirituality as a Medical Prescription" [1]; the International Journal of Cardiology: "Is Spirituality a New or Renewed Tool?" [2] and European Heart Journal: “Ten tips for promoting cardiometabolic health and slowing cardiovascular aging” [4]. They have ignited discussions regarding the potential use of spirituality as a valuable medical resource. These conversations are crucial given the absence of consensus on the conceptual framework of spirituality. For instance, the former publication outlines: 

“Religiosity/spirituality, at its core, deals with the health of the mind, and in parallel with the exercises required to maintain a healthy body, the goal of religiosity/spirituality is to prescribe activities in order to maintain a healthy mind: breath work every two hours, chakra meditation once a daily, and self-reflection as needed”.

The 10 tips4 mentioned above are behavioral habits of people engaged in spiritual practices or involved in the process of spiritualization and the authors say explicitly: Reduction of mental stress and promotion of emotional and spiritual well-being and foster meaningful relationships, altruism, and compassion. The religious practices may differ in cultural diversity and may be given distinct consideration by practitioners of spiritual activities. The concepts may lead to some confusion about the meanings of certain words and could be understood as suggestions of practices for those seeking spiritual values. The Updated Guidelines for Cardiovascular Prevention of the Brazilian Society of Cardiology³, as published in the Brazilian Archives of Cardiology, encompass principles that are in harmony with Brazilian cultural values, yet deviate from those encountered in works from other cultural backgrounds.

In the paper Spirituality as new Tool² we realize that is imperative to standardize the terminology in question. The Brazilian Society of Cardiology houses a specialized department dedicated to the examination of spirituality, named DEMCA (Department of Spirituality and Cardiovascular Medicine of the Brazilian Society of Cardiology). This department encompasses over 700 cardiologists for whom spirituality is defined as, “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.”. It is crucial to note that this definition operates akin to a living document, subject to updates with the integration of new research. These values can be construed as conscious states necessitating will, volitional impetus and must be amenable to observation and quantification. While seemingly implausible a few years ago, present-day capabilities encompass the quantification of various values - including gratitude, optimism, life purpose, forgiveness, and the proclivity for forgiveness. 

The 74th Annual Scientific Session of the American College of Cardiology featured the presentation of the FEEL Trial during the Late-breaking clinical trial session. This trial aimed to assess the impact of a spirituality-based intervention on patients with controlled blood pressure, central hemodynamics, and endothelial function. The results showed that the intervention led to an enhancement of the outcomes achieved with established conventional therapies, suggesting a potential shift in our approach to managing conditions classified as resistant or refractory hypertension. The study also highlighted the potential oversight of the non-material dimension of human physiology and hinted at the possibility of addressing the enduring challenge of residual risk in cardiology. 

The primary objective of the FEEL study was to determine whether patients with mild or moderate controlled hypertension could achieve a reduction in blood pressure over a twelve-week period by participating in a spirituality-based intervention compared to a control group. 

Additionally, as a secondary goal, the study aimed to analyze and compare blood pressure and central hemodynamic parameters as well as flow-mediated dilation after the twelve-week period, both between the intervention and control groups, and within each respective group. 

While it is a pilot study that requires replication, it is the outcome of a collaboration between two important departments of the SBC, DEMCA and DHA (Department of Arterial Hypertension). The study was meticulously organized by experts in the fields of hypertension and spirituality and effectively conducted by the specialized hypertension service of the University of Goiás. The study involved 101 randomized patients, with 51 in the intervention group and 50 in the control group, a substantial number for a pilot study. This demonstrates the efficacy or at least the plausibility that further investigation and implementation into clinical practice are necessary.

The study addresses questions such as the number of therapies that promote improvement in endothelial function as perceived by flow-mediated dilation and other interventions that have consistently reduced blood pressure in already controlled situations. And maybe these devices offer a solution for patients in serious distress with diagnoses of resistant or difficult-to-control hypertension. Taking into account the words of Karl Popper, a significant philosopher in science who once said, "It only takes one black swan to prove that not all swans are white."

The Mind-Heart-Body Connection has sparked ongoing debate and is progressively gaining recognition from respected medical organizations like the American Heart Association which has issued a statement [5] on this connection. It's clear that the mind, heart, and body are not only interconnected but also interdependent, influencing illness and various physiological processes. It's important to also acknowledge the cognitive processes involved in life events and interpersonal relationships.

The ability to observe, analyze, and understand internal and external experiences, along with the subsequent responses to adversity, significantly impacts overall health beyond mere behaviors and actions. Emotions and thoughts manifest in illnesses, affecting not only the patient but also the medical professional who listens attentively. This professional not only listens but also must empathetically steps into the patient's "psychic atmosphere" and helps them understand the life circumstances they are experiencing. This intellectual and mental state can be pivotal in understanding the patient's illness.

The impact of spirituality can be felt almost immediately or may take time to manifest, similar to how we take time to comprehend a written text. It becomes more noticeable when patients are experiencing severe conditions or dramatic situations. This effect is particularly pronounced when the patient's life or important values are at risk, as spirituality is important to the majority of our patients. According to literature, this impact could affect almost 100% of them.

Neglecting these aspects may lead us to overlook our patients' greatest concern and major need. Maybe we need to reevaluate the old concepts of "ancient" medicine. Luke, the patron saint of medicine, using mainstream practices of his time which already contemplated our being divided into three aspects and declares in the sacred texts: "and Mary said (the body), my soul doth magnify the Lord, and my spirit hath rejoiced in God my Saviour”. Or even: “thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind”. It is a remarkable opportunity to live in an era where we can utilize consistent medical research data to substantiate and integrate ancient concepts into contemporary medical science.