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    3 Comments for this article
    "Justified Optimism?"
    Andrew Kahr, Ph.D. | Harvard University
    Optimism, "expecting good things to happen in the future," very likely correlates with the probability that good things will in fact happen in the future--and not (only) because confidence improves outcomes. If your spouse is dying, you'll be pessimistic--and the future very likely will be bad. If your book got good reviews, you'll be optimistic that it will sell well. This correlation could easily have been evaluated and confirmed in any of these studies.

    When bad things actually happen or become more likely, you're more likely to die. Pessimism is predictive of these events.
    /> The underlying studies and this "Original Investigation" ignore the obvious to beat the drums once again for "Positive Psychology," the religion of our age.
    Dr Hana Fayyad, Pediatrician | American University of Beirut graduate
    “EEG studies revealed that a greater physiological activity in the frontal parts of the LH, relative to the RH, is associated with a higher self-esteem [78, 79], a general sense of happiness and well-being [80, 81], as well as a better resilience and recovery from an abusive childhood [82]. In contrast, greater physiological activity in the frontal parts of the RH is associated with an increased risk of feeling hopeless about negative events in one's life, and a higher likelihood of falling into depression [83]. Likewise, neurological reports suggest that LH stroke patients, whose emotional and psychological profile presumably reflect the intact RH, have a relatively lower self-esteem [84], and their caregivers suffer from greater stress [85], as compared to RH stroke patients. These studies demonstrate how a high self-esteem and good appreciation of oneself are associated with the LH, while a low self-esteem and a negative attitude are linked with the RH.

    The RH greater involvement in mediating fearful experiences is reflected also in its significant role in regulating the stress hormone cortisol. Higher levels of cortisol induced by stress and anxiety correlated with a greater RH activation [200-204]. There is evidence that post-traumatic stress disorder (PTSD) - where the original mental trauma is re-experienced through flashbacks and nightmares that re-activate the fear and stress responses - is coupled with an increase in RH activation [205-209]. Similarly, panic disorder and social phobia are associated with a RH hyperactivity [210-216].”

    It is thus plausible that a more balanced interplay between “happiness hormones” brings about optimism, and is itself a basic promoter of good health and body function.
    Can Real World Evidence Capture Lifestyle and Life Attitude Effects Accurately? The effects of Optimism on Cardiovascular and Mortality Risk
    Cynthia Gong, PharmD, PhD, Sang Kyu Cho, PharmD, MPH, MS, Roy Zawadzki, Jeffrey Tran, MD, Luanda Grazette, MD, MPH, Nadine K. Zawadzki, MPH, Joel W. Hay, MA, MPhil, PhD | University of Southern California
    Co-authors: Sang Kyu Cho, PharmD, MPH, MS, Roy Zawadzki, Jeffrey Tran, MD, Luanda Grazette, MD, MPH, Nadine K. Zawadzki, MPH, Joel W. Hay, MA, MPhil, PhD

    Determining causality with real world evidence is fraught with complexity as seen in recent JAMA Network Open papers. Rozanski et al. [1] concluded that “…optimism is associated with a lower risk of cardiovascular events and all-cause mortality”, finding a relative risk of 0.65 (95% CI: 0.51-0.78) and 0.86 (95% CI: 0.80-0.92) for the association with cardiovascular events and all-cause mortality, respectively. However, the study has not thoroughly investigated the potential effects of unmeasured
    confounders on the findings.

    Rozanski et al. [1] conclude that “…optimism is associated with a lower risk of cardiovascular events and all-cause mortality.” However, interventions promoting optimism and reducing pessimism may not actually reduce these risks. Unobservable confounders are more likely to explain the Rozanski et al. [1] results, including diet, exercise, wealth, comorbidities, cultural norms, social support networks, stress, sleep, etc. which are all known to impact the risk of CV events and mortality, as well as affect mood and optimism.

    An approach for conducting sensitivity analysis for unmeasured confounding is an E-value analysis, addressing how strong would any unmeasured confounding have to be to negate the observed results. [2] We calculated E-values for the relative risks in Table 2 in Rozanski et al. [1] (https://tinyurl.com/y6j4ag6o). Corresponding 95% CI E-values for relative risks were 1.9 for cardiovascular events and 1.4 for all-cause mortality. In subgroup analyses, no 95% CI E-values exceeded 2.5, suggesting that unmeasured confounders such as diet, comorbidity, or cultural norms could negate causal associations between optimism and cardiovascular events or all-cause mortality.

    In summary, E-value analyses suggest moderate unmeasured confounding would refute causal associations between optimism and cardiovascular events or all-cause mortality. It would be a valuable service to the scientific community if, as with p-values and confidence intervals, observational studies would routinely report E-values.

    1. Rozanski A, Bavishi C, Kubzansky LD, Cohen R. Association of Optimism with Cardiovascular Events and All-Cause Mortality: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(9):e1912200. doi: 10.001/jamanetworkopen.2019.12200.
    2. Haneuse S, VanderWeele TJ, Arterburn D. Using the E-Value to Assess the Potential Effect of Unmeasured Confounding in Observational Studies. JAMA. 2019 Feb 12;321(6):602-603. doi: 10.1001/jama.2018.21554.
    Original Investigation
    September 27, 2019

    Association of Optimism With Cardiovascular Events and All-Cause Mortality: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Department of Cardiology, Mount Sinai St. Luke’s Hospital, New York, New York
    • 2Department of Cardiology, Mount Sinai Heart, New York, New York
    • 3Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
    • 4Department of Cardiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence
    • 5Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 6Department of Cardiology, Crystal Run Healthcare, West Nyack, New York
    JAMA Netw Open. 2019;2(9):e1912200. doi:10.1001/jamanetworkopen.2019.12200
    Key Points español 中文 (chinese)

    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.


    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.