Not Just Pills — Cardiologists Must Talk Spirituality

Medscape

09-07-2025

Spirituality is becoming an area of growing interest in cardiovascular medicine as evidence mounts linking it to improved physiological outcomes and treatment adherence. Emerging research suggests that qualities such as purpose in life, gratitude, and hope — even when not tied to religious practice — may positively influence cardiovascular health.
At the 45th Congress of the Cardiology Society of the State of São Paulo, experts explored how this subjective dimension may contribute to fewer hospitalizations, better blood pressure control, and improved clinical outcomes in patients with heart disease.
Opening the discussion, cardiologist and hypertension specialist Fernando Nobre, MD, PhD, emphasized the important distinction between spirituality and religiosity. While often used interchangeably, the two are not synonymous. Religiosity refers to structured beliefs, practices, and rituals associated with faith and community life. In contrast, spirituality encompasses moral, emotional, and mental values that shape an individual's behavior and decision-making. These can be assessed using scientific frameworks.
'Religiosity is about how connected someone is to their religion — attendance at services, observance of rituals. That can be part of spirituality, but spirituality goes further. It cuts across and transcends a person's life, shaping their choices and way of living,' said Nobre, who is also a professor at the University of São Paulo, São Paulo, Brazil.
Patients with a stronger sense of spiritual engagement tend to have lower blood pressure and are less likely to develop hypertension. Studies suggest these effects may be linked to lower peripheral vascular resistance, improved cardiac output, and better adherence to prescribed treatment — particularly among women.
One recent example is the Brazilian Feel study, led by cardiologist Maria Emília Figueiredo Teixeira, MD, PhD, at the Brazilian Federal University of Goiás, Goiânia, Brazil. Cited by Nobre, the study was published in 2024 and followed 100 individuals with hypertension over 12 weeks. The intervention group received short, non-religious videos and messages promoting spiritual reflection — delivered via WhatsApp — and were encouraged to write about gratitude, forgiveness, life purpose, and optimism.
The group receiving the intervention showed a more significant drop in blood pressure and notable improvement in endothelial function, measured through flow-mediated dilation.
'If spirituality appears to influence both key components of blood pressure, that alone is reason enough for us to understand it better,' said Nobre.
Heart Failure: Fewer Hospitalizations, Better Quality of Life
In patients with heart failure, spirituality may influence not only psychological resilience but also the underlying pathophysiology of the disease. Studies have found that individuals with greater spiritual engagement show reduced sympathetic nervous system activity, lower levels of stress hormones, and decreased inflammatory cytokines. Clinically, these changes are associated with fewer symptoms, fewer hospitalizations, and an improved quality of life.
At the session, cardio-oncologist Rafael Nunes, MD, PhD, of the Oswaldo Cruz German Hospital, São Paulo, highlighted a 2022 review published in JACC: Heart Failure . The review analyzed 47 studies examining spirituality in heart failure patients. Despite differences in methodology, the evidence consistently linked higher spirituality levels with lower rates of anxiety and depression, improved adherence to treatment, fewer hospital admissions, and, in some cases, reduced mortality.
A follow-up review published in 2023 reinforced these findings and added an important distinction: Participation in religious organizations alone was not sufficient to deliver clinical benefit. 'It's the spiritual experience — the meaning a person assigns to their life, beliefs, and motivations — that is associated with positive outcomes,' explained Nunes.
Another study underscored this point. Titled Is Belonging to a Religious Organization Enough? , the study separately assessed the effects of religiosity and spirituality. The results showed that spirituality was linked to lower levels of anger, anxiety, and emotional exhaustion. In contrast, religiosity alone — without deeper personal engagement — did not significantly impact emotional well-being.
Coronary Artery Disease: Stress and Acute Cardiac Events
While coronary artery disease can remain stable for years, its progression into acute myocardial infarction — one of the leading global causes of death — can be sudden and unpredictable. Although plaque accumulation is gradual, rupture events are often triggered by acute neuro-immuno-hormonal and inflammatory responses.
Roberto Veiga Giraldez, MD, PhD, director of the Acute Coronary Care Unit at the Heart Institute, Hospital das Clínicas, University of São Paulo, cited research linking acute myocardial infarction to external stressors such as natural disasters or high-stakes sporting events. During these situations, sympathetic nervous system activation and systemic inflammation intensify, raising the risk of acute coronary syndromes.
One study cited by Giraldez was conducted in South Korea, where cities vulnerable to earthquakes experienced a significant spike in acute coronary syndrome cases immediately following seismic events. Incidence peaked shortly after the quakes and gradually declined over time.
Another analysis focused on the 2006 FIFA World Cup. In several German cities, rates of myocardial infarction rose during high-stakes national team matches — especially during tense or decisive games. The highest incidence occurred in the early minutes of play, when fan anxiety was likely at its peak.
'These data illustrate how acute stress can influence outcomes in patients with coronary artery disease,' said Giraldez. 'Spirituality can help mitigate this impact. Resignation and faith — whatever form they take — can help individuals face stressful situations with greater composure.'
How Should Clinicians Address Spirituality?
According to Nunes, spirituality should be systematically integrated into clinical practice — always with sensitivity to the patient's values, preferences, and boundaries. 'We should approach spirituality with the same seriousness we apply to mental health and lifestyle habits. Understanding what matters to the patient and why they seek care can shape the therapeutic journey,' he said.
He advocated for incorporating spiritual assessment into palliative care and broader multidisciplinary strategies, particularly in advanced stages of heart failure. 'Nutritionists, nurses, psychologists — everyone can play a role in listening,' he added.
Nobre emphasized that addressing spirituality doesn't have to be complex — just intentional. 'During the medical history, when we ask about lifestyle, why not also ask how the illness is affecting them emotionally? Or whether they believe in something greater? For some, spirituality may be irrelevant, and that's fine. But if it matters to the patient, it can become a powerful ally — especially in supporting treatment adherence.'
'We're not necessarily talking about religion,' he continued. 'A person might be Catholic, Evangelical, Umbandist, or have no religion at all. The point is: Does it matter to them? When we make that connection, care moves beyond the physical body. It becomes whole-person care — addressing mind, emotions, and values. And that's when medicine reaches its fullest potential,' Nobre concluded.