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Association of Optimism With Cardiovascular Events and All-Cause MortalityA Systematic Review and Meta-analysis

Educational Objective
To understand the evidence for the association of optimism and lower cardiovascular risk
1 Credit CME
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.


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.

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Article Information

Accepted for Publication: August 9, 2019.

Published: September 27, 2019. doi:10.1001/jamanetworkopen.2019.12200

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Rozanski A et al. JAMA Network Open.

Corresponding Author: Alan Rozanski, MD, Department of Cardiology, Mount Sinai St Luke’s Hospital, 1111 Amsterdam Ave, New York, NY 10025 (

Author Contributions: Drs Rozanski and Bavishi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rozanski, Bavishi, Kubzansky.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rozanski, Bavishi, Cohen.

Critical revision of the manuscript for important intellectual content: Rozanski, Bavishi, Kubzansky.

Statistical analysis: Rozanski, Bavishi, Kubzansky.

Administrative, technical, or material support: Bavishi.

Supervision: Rozanski.

Conflict of Interest Disclosures: None reported.

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