A mindset of optimism is associated with lower cardiovascular risk and that promotion of optimism and reduction in pessimism may be important for preventive health

Association of Optimism With Cardiovascular Events and All-Cause Mortality - A Systematic Review and Meta-analysis. Alan Rozanski et al. JAMA Netw Open. 2019;2(9):e1912200. September 27, 2019. doi:10.1001/jamanetworkopen.2019.12200


Key Points
Question  Is a mindset of optimism associated with a lower risk of cardiovascular events and all-cause mortality?

Findings  In this meta-analysis of 15 studies including 229 391 individuals, optimism was associated with a lower risk of cardiovascular events and pessimism was associated with a higher risk of cardiovascular events; the pooled association was similar to that of other well-established cardiac risk factors.

Meaning  The findings suggest that a mindset of optimism is associated with lower cardiovascular risk and that promotion of optimism and reduction in pessimism may be important for preventive health.

Abstract
Importance  Optimism and pessimism can be easily measured and are potentially modifiable mindsets that may be associated with cardiovascular risk and all-cause mortality.

Objective  To conduct a meta-analysis and systematic review of the association between optimism and risk for future cardiovascular events and all-cause mortality.

Data Sources and Study Selection  PubMed, Scopus, and PsycINFO electronic databases were systematically searched from inception through July 2, 2019, to identify all cohort studies investigating the association between optimism and pessimism and cardiovascular events and/or all-cause mortality by using the following Medical Subject Heading terms: optimism, optimistic explanatory style, pessimism, outcomes, endpoint, mortality, death, cardiovascular events, stroke, coronary artery disease, coronary heart disease, ischemic heart disease, and cardiovascular disease.

Data Extraction and Synthesis  Data were screened and extracted independently by 2 investigators (A.R. and C.B.). Adjusted effect estimates were used, and pooled analysis was performed using the Hartung-Knapp-Sidik-Jonkman random-effects model. Sensitivity and subgroup analyses were performed to assess the robustness of the findings. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline was followed.

Main Outcomes and Measures  Cardiovascular events included a composite of fatal cardiovascular mortality, nonfatal myocardial infarction, stroke, and/or new-onset angina. All-cause mortality was assessed as a separate outcome.

Results  The search yielded 15 studies comprising 229 391 participants of which 10 studies reported data on cardiovascular events and 9 studies reported data on all-cause mortality. The mean follow-up period was 13.8 years (range, 2-40 years). On pooled analysis, optimism was significantly associated with a decreased risk of cardiovascular events (relative risk, 0.65; 95% CI, 0.51-0.78; P < .001), with high heterogeneity in the analysis (I2 = 87.4%). Similarly, optimism was significantly associated with a lower risk of all-cause mortality (relative risk, 0.86; 95% CI, 0.80-0.92; P < .001), with moderate heterogeneity (I2 = 73.2%). Subgroup analyses by methods for assessment, follow-up duration, sex, and adjustment for depression and other potential confounders yielded similar results.

Conclusions and Relevance  The findings suggest that optimism is associated with a lower risk of cardiovascular events and all-cause mortality. Future studies should seek to better define the biobehavioral mechanisms underlying this association and evaluate the potential benefit of interventions designed to promote optimism or reduce pessimism.


Introduction

Extensive evidence has demonstrated an association between negative emotions, social factors, and certain chronic stress conditions and adverse cardiac outcomes.1 Less well studied has been the potential association between positive and negative mindsets and cardiac risk. Such research is of interest because mind-sets are potentially modifiable, thus making them a novel relevant target for clinical intervention. One such mindset is an individual’s level of optimism, commonly defined as the tendency to think that good things will happen in the future.2 Empirical studies have long indicated that more optimistic individuals are more likely to succeed at work and in school, sports, politics, relationships, and other forms of life endeavors.3,4 A more recent study also reported positive associations between optimism and a range of favorable physical health outcomes.5 Nevertheless, the assessment of optimism and pessimism in cardiac medical practice is uncommon. In 2001, Kubzansky and colleagues6 reported the first study, to our knowledge, to find an association between higher optimism and a lower risk for specific cardiac outcomes, including angina, myocardial infarction, and cardiac death. They showed effects of optimism beyond those of depression or other forms of psychological distress, a critical finding because a concern about such findings is that they simply reflect the absence of depression rather than active effects of optimism. Since then, similar findings have been described in other studies,7-20 and most studies considered depression or distress as a potential confounder. To consider these findings more systematically, we conducted a meta-analysis of studies that have assessed the association between optimism and pessimism and adverse cardiac outcomes. Our goals were to evaluate the magnitude of this association, the consistency of results among reported studies, the influence of potential confounders, and the quality of the reported literature.