Mental Outlook Linked to Long-term Survival After CHD Hospitalization

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Patients hospitalized for coronary heart disease (CHD) who express high expectations for recovery later see their positive outlook come to fruition, according to a paper published online February 28, 2011, ahead of print in the Archives of Internal Medicine. The most optimistic patients had improved functioning at 1 year and better survival at 15 years.

Although recovery expectations have been shown to predict the physical and social functioning of CHD patients, less is known about the relationship between such beliefs and subsequent clinical events, report John C. Barefoot, PhD, of Duke University Medical Center (Durham, NC), and colleagues.

To address this gap, the researchers evaluated 2,818 patients (75% of the eligible population) who underwent diagnostic coronary angiography at their center from 1992 to 1996 and were found to have clinically significant disease (≥ 75% diameter stenosis). During the index hospitalization, patients were interviewed using the Expectations for Coping Scale, which asks 18 questions about expected future lifestyle and cardiac prognosis. Functional follow-up was obtained at 1 year, and mortality was assessed through 15 years.

Baseline Beliefs Matter

Over the course of follow-up, 45.3% of the cohort received CABG, 41% underwent PTCA, 14.1% had both surgical and percutaneous interventions, and 27.7% were treated with medical therapy.

After controlling for baseline clinical, demographic, and psychosocial differences, recovery expectations were positively associated with the likelihood of both total and cardiac mortality at 15 years (table 1).

Table 1. Association Between Survival and Expectations: 15-Year Follow-up


Adjusted HR

95% CI

Total Mortality



Cardiac Mortality



By 1 year, 53.8% of patients showed an improvement in function according to the Duke Activity Status Index and 35.2% exhibited a decline. Multiple regression models demonstrated that recovery expectations predicted functional status (P < 0.001).

The study authors propose 2 plausible mechanisms for the observed survival benefit. The first is that a positive outlook may lead to better coping strategies and healthier behaviors. The second is that “those with pessimistic expectations will experience more tension and negative emotions during the recovery period, resulting in heightened stress reactions, autonomic dysregulation, and other physiological responses that increase the risk of cardiac events,” the researchers write.

Expectations Independent of Other Factors

Speaking with TCTMD in a telephone interview, Dr. Barefoot said the biggest surprise from the study was that the effect of expectation was independent of depressive tendencies, which are a known marker for poor survival, and of social relationships. “So the fact that it’s in addition to those things caught my eye,” he noted.

Although the paper notes several limitations such as possible unmeasured confounders and selection bias, he said the relationship between recovery expectations and survival appears realistic. However, “I’d like to see it repeated. The second thing is that we have some initial evidence [showing] the feasibility of working with patient beliefs and changing them fairly easily, but we don’t know whether that’s going to have any effect on health yet,” Dr. Barefoot commented. “So I think we need some trials before we can really make recommendations for what people should be doing in practice.”

He described preliminary research from New Zealand in which MI patients attended in-hospital counseling sessions to discuss the causes of disease and develop strategies to change behavior. Spouses also were involved in the process. Although the sessions were not specifically geared toward changing recovery expectations, they did reduce anxiety, facilitate return to work, and improve diet and exercise habits, he reported.

Similarly, Dr. Barefoot suggested, counseling sessions designed to affect expectations might motivate patients and consequently improve clinical outcomes. “People who really believe they’re going to recover probably have higher levels of motivation,” he said. “They’re more persistent and don’t sit around and worry about things” but instead deal with the problems at hand.

Balancing Optimism and Honesty

In a commentary accompanying the paper, Robert Gramling, MD, DSc, and Ronald Epstein, MD, both of the University of Rochester (Rochester, NY), agree that the degree of benefit observed by this and other studies “suggest that optimism is a powerful ‘drug’ that compares favorably with highly effective medical therapies.”

But while it may be tempting to “consider ourselves ethically justified in withholding or obfuscating poor prognoses from patients,” they acknowledge, “the effects of an unbridled optimistic ‘overdose’ can be disastrous.”

Patients with incurable illnesses, for example, might choose burdensome treatments that “not only lower their quality of life and complicate their loved ones’ bereavement but also possibly shorten survival. It is important to note that extreme or unbalanced optimism may leave patients unprepared, alone, or devastated when the reality of the situation sets in,” Drs. Gramling and Epstein stress, pointing out that clinicians have a duty to be honest with patients.

They suggest that a “hope for the best, prepare for the worst” strategy appears best.

Dr. Barefoot agreed that the remarks of Drs. Gramling and Epstein are on target. “I don’t think we want to unnecessarily raise optimism to the point where it’s deleterious, but I do think this is promising,” he said, advocating for future trials to evaluate whether counseling sessions could optimize recovery expectations.

Study Details

In all, 3,737 qualifying patients enrolled but 368 were excluded due to missing information and 551 did not complete the expectations interview. Thus, the basic mortality analyses were conducted in a cohort of 2,818 patients (75% of the eligible population). Those without complete data on expectations tended to be male, older, and have more severe disease. An additional 426 patients were absent from the 1-year functional analyses. Excluding those who died, the remaining patients were more likely to have CHF, diabetes, and peripheral vascular disease. They also had reduced expectations of recovery.


1. Barefoot JC, Brummett BH, Williams RB, et al. Recovery expectations and long-term prognosis of patients with coronary heart disease. Arch Intern Med. 2011;Epub ahead of print.

2. Gramling R, Epstein R. Optimism amid serious disease: Clinical panacea or ethical conundrum? Arch Intern Med. 2011;Epub ahead of print.



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  • The study was funded by grants from the National Heart, Lung, and Blood Institute with additional funding from the National Institute on Aging.
  • Drs. Barefoot, Gramling, and Epstein report no relevant conflicts of interest.