(Txt): “Hi Glenn-Running 25 minutes late, sorry ; )”

(Upon Arrival): “Hey I’m really sorry but have you got any change? I need to feed the meter.”

(Settling In): “So what is it you do again? What’s this Practice Fusion thing?”

(Later) “You should meet this cocky, self-absorbed 22 year-old with no entrepreneurial experience and no network who I just met. He’s doing something just like you.”

“So how are you different from this other company I just invested in?”

Sigh.

Noted university scientist lands $20m government grant to study link between an unmodifiable human trait and survival.

Scientist finds a borderline significant correlation, but only in tall females who raise llamas.

University press release mistakes correlation for causation, implies findings apply to all people.

Erroneous release tweeted 6 million times.

Scientist appears on 18 morning talk shows (including one with a tall female and 6 random llamas).

Scientist secures $20m from private investors to commercialize test for the unmodifiable human trait.

Sigh.

40 million people have no health insurance, 20 million kids live in poverty, the obesity epidemic remains unchecked…and The Tone Deaf Entrepreneur releases THIS?

Noted VC firm invests $10m in company led by The Tone Deaf Entrepreneur.

TechCrunch all over incredible story of The Tone Deaf Entrepreneur.

Tone Deaf app fastest-ever to 1 million downloads.

Three months pass.

No one is using the Tone Deaf app. People can’t remember who The Tone Deaf Entrepreneur is. Noted VC firm updates portfolio company list.

40 million people still have no health insurance, 20 million kids still live in poverty and the obesity epidemic remains unchecked, still.

Sigh.

Dear Pizaazz Readers-Thanks for stopping by!

Recently, I haven’t had time post regularly because I’ve been busy launching a startup company called Wellcoin. It’s in the consumer health space, and it’s based on a tremendous concept. At least I think so!

For updates on Wellcoin, please check our web site or follow us on Twitter. As for Pizaazz, I’ll be back at it soon!

Thanks, Glenn

Positive Health, a breakthrough concept developed by Martin Seligman, encourages us to promote positive health assets—things like optimism, connectedness, a stable marriage and so forth—because  they contribute to a healthier, more fulfilling life and yes, improved life expectancy.

In earlier posts in my series on Positive Health, I reviewed 2 studies which support Seligman’s concept. In the first, Harvard scientists showed that emotional and cognitive well-being was associated with a reduced rate of coronary events.  In the second, University of Michigan scientists showed that optimism was an independent predictor of short term stroke risk.

While both studies suggest that the presence of certain positive health assets can be protective, they do not look at whether the absence of certain negative attributes can be similarly helpful. Recently, scientists at the Karolinska Institutet undertook to study this aspect of Positive Health. Once again, their findings support Seligman’s concept.

As was the case for the first 2 studies, support for the new study was provided by the Robert Wood Johnson’s Pioneer Portfolio.

In the new study, Francisco Ortega and colleagues set-out to study the association between psychological well-being and cardiorespiratory fitness, and their combined effects on survival.

The scientists used data from the Aerobics Center Longitudinal Study (ACLS), a prospective epidemiologic investigation of more than 5,000 volunteers that began in 1988. At the time of enrollment, participants had a thorough clinical evaluation including a history, physical exam, blood chemistry tests and an exercise test. Participants ranged in age from 20-81 and were followed annually until they died or the study ended, in 2003.

In ACLS, psychological well-being was evaluated at the time of enrollment using negative and positive emotion subscales from the Center for Epidemiologic Studies depression (CES-D) test. Questions in this test asked about how frequently respondents experienced certain feelings in the preceding week. The negative emotion subscale included things like my life had been a failure, not able to shake off the blues, depressed, sad, fearful, lonely and crying spells. The positive emotion subscale included things like feeling as good as other people, happy, hopeful, and joy.

What Did They Find?
After adjusting for traditional cardiovascular risk factors, the scientists found that participants with low levels of negative emotion had a 34% lower risk of death than peers reporting high levels of negative emotion. The protective effect was localized to those with high levels of cardiorespiratory fitness (CRF): high levels of CRF were themselves associated with a 46% reduction in mortality risk, but in the subset of participants that had both high levels of CRF and low levels of negative emotion, there was a 63% lower mortality risk.

These associations were present across all age groups and both genders. They persisted after adjusting for the presence of underlying diseases and the impact of positive emotion. Interestingly, high levels of positive emotion were not associated with mortality.

What Do We Make of This?
Ortega’s study suggests that low levels of negative emotion and high levels of cardiorespiratory fitness are independent predictors of long-term survival. What is more, these two parameters exerted a strong combined effect such that participants having both low-level negative emotion and high CRF experienced a 63% lower mortality risk than those with high negative emotion and low CRF.

This study should be considered in light of several limitations, as noted by the authors. For example, although they controlled for many risk factors for premature mortality, it may be that uncontrolled factors like dietary habits could also have played a role. These data were not available to Ortega’s group.

In addition, nearly 98% of the ACLS participants were well-educated, white, and in middle or high socioeconomic strata. It remains to be determined whether these findings will hold up in populations with more varied ethnicity and socioeconomic status. Also, the ACLS provided only a baseline assessment of negative and positive emotion. Although the authors cite previous studies suggesting that measures of psychological well-being remain stable over time, this assertion doesn’t necessarily jive with my anecdotal experiences (!).

Finally, the beneficial effect of low-level negative emotion on survival was seen only in participants with high levels of cardiovascular fitness. It did not impact those with low or moderate CRF levels…a strange, inexplicable finding that bears further scrutiny.

These limitations mean it’s unwise to recommend at this time that health professionals should routinely assess psychological health of their patients during, say, an annual physical examination, or that providers should intervene to reduce negative emotions (if that’s possible) in addition to encouraging increased physical activity. That said, the current study suggests a lot is at stake. If the findings do hold up in follow-up investigations, we might well have another compelling way to help people maintain health.

It’s worth mentioning in closing that Ortega’s group found only a modest correlation between positive and negative emotion scores: people with high levels of positive emotion do not necessarily have low levels of negative emotion, and vice versa. The group concluded that positive and negative emotion are distinct from each other and can impact survival in their own, unique ways.

Ladies and gents, I’m Glenn Laffel, the father of the bride. On behalf of my wife Lori and Mindy and Roy Kaufman, I welcome you to our celebration of Nikki & Ben’s wedding. Many of you have come a long way to join us. We’re honored and thankful that you came.

Off the bat, I want to say how proud I am to have accompanied Nikki today.

Nikki, I have never seen you more beautiful then you are right now. I am amazed at what you have achieved already. You were a 2-time state champion swimmer in high school. You got into Princeton when you were 16 years old. And you’ve managed a dozen different projects in a dozen different factories—on the ground, in China—to get the world’s coolest products to market, on time.

I look at your remarkable productivity, and what I see is your mother, who has had her share of success over the years, as well. I am proud that you take after her in areas that matter to me.

Every dad hopes his daughter will find a reliable, sensible, considerate partner and you know, you try not to interfere in their lives, but you do hope your children will make the right choices in life. Nikki chose Ben.

Nikki, in Ben you have found a perfect partner. He does the driving. He takes you shopping. He sets up your Wi-Fi and your iPhone. He even folds laundry, though he does put it on the couch where he just napped, buck naked!

Beginning today, Ben is the most important person in your life, Nikki. Mommy and I, your sisters, grammy and grampy, we are always here for you, but Ben is the last person you see before you close your eyes for sleep every night. So before you do that every night, Nik, look at this man and remind yourself that he is Ben Kaufman. He is your husband. He is the most important person in your world, now and forever.

And Ben, you are as amazing as your bride, and I admire you. You were named one of the nations’ top entrepreneurs under the age of 30, when you were barely 20! You sold a company to Carmelo Anthony. You were invited to the White House because of your success as an entrepreneur. You have lectured at Stanford, MIT and RISD, and there’s more where that came from.

So just one quick story. I said that Ben does all the driving with Nikki. So he and I have this thing where, when it’s safe, he texts me to say that Nikki has fallen asleep in the car. This usually takes about 3 minutes. I love that message because, first of all Lori does that too, but also it comforts me because what he’s saying is he’s taking care of my daughter. Ben will always do that, I know, and that’s a big reason why I’m so happy tonight.

OK so that’s it from me! Just please let me propose a toast to the new couple. Ben, Nikki, I wish you a lifetime of happiness together. May you fulfill all the hopes and dreams you have for yourselves and each other. And may your bond as a married couple gain strength, each and every day.

Way back in 1946, the chartering documents for a new agency of the UN—the World Health Organization—defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

We have made astounding progress in medicine and public health since the WHO charter was crafted, yet we have actualized only part of its comprehensive vision for health. What we call health care today is really just illness care. Even our disease prevention and health promotion programs focus on reducing risk factors for disease. It is the rare initiative indeed that encourages good health for its own sake.

New initiatives focused on the concept of Positive Health are changing that by helping us understand what it means to be healthy in a comprehensive sense, beyond the simple absence of symptoms and illnesses. The initiatives focus on health assets, which are biological, psychological, social and other characteristics that are associated with prolonged life, reduced morbidity and health care costs, and improved quality of life.

The initiatives have been triggered in large part by the seminal contributions of Martin Seligman. Many are funded by the Robert Wood Johnson Foundation’s Pioneer Program. They have already produced provocative results, one of which I discussed last week.

In this post–the second in a continuing series–I review another initiative in the field of Positive Health. This one examines how optimism impacts the risk of stroke, the nation’s third leading cause of mortality and disability after heart disease and cancer.

The Study
The classic risk factors for cardiovascular disease (including stroke) include high blood pressure and cholesterol levels, cigarette smoking and diabetes. ‘Negative’ psychosocial factors like depression, anxiety, work stress, low socioeconomic status and poor social support also predict cardiovascular events. More recently, a few studies have filtered into the literature suggesting that health assets like life satisfaction are also predictive.

However, as the National Heart, Lung and Blood institute recently emphasized, essentially none of these factors are all that good at predicting near term (that is, 1-2 years) cardiovascular events, especially in asymptomatic adults. Furthermore, almost no studies have examined whether positive health assets can impact the risk of stroke, per se.

A study by Eric Kim, of the University of Michigan, and colleagues has addressed this opportunity. They concluded that optimism was in fact an independent predictor of short term stroke risk.

To reach this conclusion, Kim’s group looked at data from 6,044 adults with no prior history of cardiovascular or cerebrovascular disease. The subjects had participated in the Health and Retirement Study, a nationally representative, prospective study of Americans who were at least 50 years old.

The scientists assessed optimism using the Life Orientation Test, in which participants respond to 3 questions using a 6-point Likert scale. Kim’s group created an ‘optimism scale’ based on participants’ responses. The scale ranged from 3 (extremely pessimistic) to 18 (extremely optimistic).

It turned out across the entire survey population, each unit increase on the scale was associated with an age-adjusted 9% decrease in stroke-risk during the 2 year follow-up.

Negative psychological factors like anxiety, depression and neuroticism were also predictive of short-term risk for stroke, but optimism offset their impact.

Of note, the association between optimism and stroke risk persisted after controlling for cardiac disease and dozens of biological, behavioral and sociodemographic factors (including race/ethnicity, marital status, educational status, cigarette smoking history, exercise, alcohol use, diabetes, body mass index, blood pressure).

What Can We Make of This?
Kim’s study is the first to suggest that optimism may protect against stroke in older adults. It is consistent with other research which has shown that positive psychological factors like optimism are associated with a range of cardiovascular benefits, including a reduced risk of rehospitalization following bypass surgery, reduced  risk of coronary heart disease and even reduced cardiovascular mortality.

One potential flaw in Kim’s study is that stroke incidence was ascertained via self-reporting from participants, based on what they understood from their doctor or by proxy reports for participants that had died (many of the covariates were also self-reported in Kim’s study). According to Kim’s team however, self-reported stroke has been shown in several other studies to provide an accurate estimate of stoke incidence.

Why might optimism reduce stroke risk? Kim’s group mentioned several studies showing that high optimism is associated with health knowledge and the pursuit of healthy behaviors. They hypothesized that optimists might be more proactive about their health in general, perhaps by adopting a healthier lifestyle that minimizes health risks and increases health and well-being.

These theories make sense but require further validation, especially before we can comfortably recommend interventions designed to promote optimism in the effort to reduce the incidence of stroke.

In recent weeks, several Democrats and some health reform advocates including the AMA have joined Republicans in calling for a repeal of provisions in the new health law that create the Independent Payment Advisory Board (IPAB). For these people, IPAB represents the worst aspects of the new law–an unelected, centralized planning authority empowered by government to make decisions about the peoples’ health care. Arbitrary cuts to providers, short-sighted decisions that stifle innovation and rationing of care are sure to follow, they claim.

While it’s true that the rules governing IPAB are flawed and should be fixed, eliminating IPAB altogether would be a mistake.

Created by the Affordable Care Act, IPAB is a fundamental part of the law’s plan to control health care cost escalations. The law contemplates that each of the Board’s 15 members would be appointed to a 6-year term by the president. Members are to include providers, health policy and public health experts, and consumer representatives. Each would have to be confirmed by Congress, much like Supreme Court justices. And unlike a frightening, wizard-like bureaucrat operating behind a curtain-as critics would have you believe-the IPAB chairperson would be required to appear before any committee of Congress that desires a hearing, just as the President’s cabinet members are required to do.

IPAB’s mandate would be to recommend ways to prevent excessive escalations in per capita Medicare expenditures. Specifically, whenever these costs grow faster than targets established by the Affordable Care Act, IPAB would propose ways to reduce Medicare spending by up to 1.5%. When that happens, Congress can either approve those recommendations, develop alternatives with the same impact, or simply allow Medicare costs to accelerate. In the last instance, a 60% majority of the Senate would be required to overrule the IPAB recommendation.

Some sort of cost-governing approach is mandatory, because we want to offer comprehensive coverage to Medicare beneficiaries within some reasonable cost structure, and because Congress has shown no inclination to do so, for example by enacting quality- and efficiency-based payment models. As Jonathan Cohn points out, Congress is unlikely to do this going forward, either, because its members are heavily influenced by lobbyists whose job it is to maintain the lucrative status quo. IPAB members, shielded as they should be from such influences but still wholly accountable to Congress, may well succeed where lawmakers have not.

Some of those who are now calling for a repeal of IPAB predict it will release “treatment edicts” that prevent folks from gaining access to expensive procedures, cancer drugs and so forth. These predictions are unlikely. The Affordable Care Act prohibits IPAB from modifying Medicare benefit schemes or any other behavior that could be construed as “rationing.” It also prohibits IPAB from raising premiums, restricting benefits or modifying eligibility.

So What Will IPAB Do?
When medical research suggests that certain treatments are more effective, or cost-effective (I provide an example involving coronary stenting here), IPAB is authorized to recommend changing reimbursement rates under Medicare to promote such treatments. These recommendations do not ration care. Providers can practice medicine as they see fit. The new reimbursement scheme will incent providers, however, to heed the research sooner, and more comprehensively than would otherwise be the case.

Let’s not forget that all payers, private and public, already routinely decide what procedures to cover. In effect, IPAB can increase input by scientists and cuts down input by lobbyists when it comes to coverage decisions.

Critics have also charged that by cutting reimbursement to providers, IPAB might indirectly foster rationing. According to this argument, cash-strapped providers will begin turning-away Medicare beneficiaries if their payment is reduced too far. As Cohn points out however, these criticisms have never raised above the anecdotal stage. Most doctors still see Medicare patients; in fact they are more open to seeing such patients than to many of those insured through private carriers.

Is there room to improve current legislation governing IPAB? Yes, there is. According to Henry Aaron, IPAB can’t make recommendations governing acute and long-term care hospitals, psychiatric facilities and inpatient rehabilitation until 2020. It can’t do that for clinical labs until 2016. In their current form, IPAB rules also prevent recommendations that drive up costs in the short run, even though they might save money in the long run. These rules should be fixed, for obvious reasons. But repeal IPAB altogether? Heavens no!

It is ironic that the loudest critics of health reform–the ones who claimed it didn’t have enough teeth to control Medicare cost escalation–are the same ones who now demand that IPAB, a key element of the law’s cost-control strategy, be repealed.

If none of this is persuasive, consider the alternative proposed by Paul Ryan and supported by Republicans in the House. Rather than empowering a commission to improve Medicare efficiency, it severely reduces the scale of the entitlement program altogether. It offers seniors a voucher that provides less comprehensive coverage than today’s Medicare, and forces seniors to fend for themselves in the private insurance market, just as they did before LBJ created Medicare in the first place.

Few if any seniors want to revisit those days.

The Case
In 2009, administrators at St. Joseph Medical Center in Maryland wrote letters to patients of Mark Midei, informing them that its staff cardiologist may have subjected them to a coronary artery stenting procedure inappropriately. That communication prompted an article in a local newspaper, which triggered an investigation by the Senate Finance Committee.

The Committee subsequently released a report which asserted that Midei performed nearly 600 stenting procedures unnecessarily, and charged Medicare nearly $4m for these procedures. According to the report, all the procedures involved stents made by Abbott Labs. Abbott, in turn, had paid Midei $31,000, added him to its roster of top stent volume cardiologists, and feted him with a pig roast at his home to celebrate a prodigious day in which he implanted 30 stents (apparently a company record). Then, after St. Joseph’s dropped Midei from its roster, Abbott hired him to provide services in Japan and China. In the subsequent year, the number of patients who received stents at the hospital fell to 116 from 350 in the previous year.

Most recently, the Maryland Board of Physicians revoked Midei’s license to practice medicine after concluding that he did implant stents into the coronary arteries of 4 patients inappropriately. The Board also determined that he exaggerated the severity of coronary blockages, and claimed incorrectly that they had unstable angina. Midei has denied the allegations and sued St. Joseph for damaging his career.

The Context
The Midei case is particularly egregious, but a recent study in the Journal of the American Medical Association suggests that many thousands of percutaneous coronary interventions (PCIs)—perhaps as many as 4% of all those performed each year in the US—are inappropriate.

The study was organized by Paul Chan of Saint Luke’s Mid America Heart and Vascular Institute. Chan’s team found that when PCIs were done for acute indications like an evolving myocardial infarction (heart attack), the overwhelming majority of cases (98.6%) were performed for appropriate indications. A remarkably low 1.1% were done inappropriately (in the other cases, the benefit was uncertain).

For elective procedures like the ones performed by Midei however, fully 11.6% of all PCIs were inappropriate, and an additional 38% were carried out for indications associated with unclear benefits. Most of the procedures deemed to be inappropriate were carried out on patients with no angina (54%), low-risk ischemia as determined by exercise testing (72%), or patients that were not receiving ‘maximal’ medical therapy (96%). Ninety-four percent of these patients also did not have ‘high risk’ coronary anatomical findings.

Chan’s group found enormous variation across hospitals in the rate of inappropriate elective PCIs, with the range being 0% to 55%. The best-performing quartile had 6% or fewer inappropriate PCIs, while the worst quartile had 17% or more.

To determine which PCIs were done for appropriate indications, Chan’s group used criteria released in 2009 by a task force which included representatives from the American College of Cardiology, the American Heart Association, the American Association for Thoracic Surgery, the Society for Cardiovascular Angiography and Interventions (SCAI), the American Society of Nuclear Cardiology and the Society of Thoracic Surgeons.

The scientists used data from the CathPCI registry which included information on more than 500,000 procedures performed at more than 1,000 US hospitals between July, 2009 and September, 2010.

Just over 70% of all procedures were done for acute indications, including ST-segment elevation MI (STEMI), non-STEMI, and certain high risk patients with unstable angina with high-risk features. The others were elective.

How Many Stents are Enough?
Nearly 600,000 percutaneous coronary interventions (PCIs) are performed per year in the US. Patients receiving the expensive procedure are exposed to procedural complications, and an increased risk of bleeding and stent thrombosis. Trials in patients with ‘stable’ cardiovascular disease reveal that PCI provides no better than modestly improved symptoms, when compared to medical therapy.

Given this, few cardiologists would be pleased to hear that one out of eight elective PCIs is performed for reasons deemed by experts to be inappropriate. My guess is that many of the inappropriate procedures can be traced upstream to earlier decisions to perform diagnostic catheterizations in the first place, perhaps motivated by a borderline result on an exercise tolerance test, or unwillingness by the patient or the physician to give medical therapy a full, fair trial. Once an invasive diagnostic procedure like this is undertaken, it can be awfully tempting to treat borderline lesions with PCI and stenting, even though these lesions are unlikely to be life-threatening anytime soon.

A second factor, cited by Chan’s group, is that Cardiologists don’t always agree with, or understand the guidelines crafted by their peers. In fairness, guidelines developers assume ‘average’ proficiency with the PCI procedure. For extremely talented clinicians, the risk-benefit ratios assumed by developers may not reflect results on the ground. Still, for Cardiologists who aren’t familiar with the guidelines, simple educational programs are likely to improve outcomes.

In part, this is why 38% of the elective PCIs in Chan’s study were done for ‘uncertain’ indications. Additional research is required understand how PCI can benefit certain patient populations, and how variable skill-levels among Cardiologists can affect recommendations.

And let’s not overlook the patients’ role in medical decision making, especially in areas deemed as uncertain by the experts. Some patients can tolerate and comply with complex medical regimens better than others. Some patients can more easily afford to pay for expensive, lifelong medical therapies. In Cardiology as in other disciplines, the practice of medicine is often not black and white. This is why clinical judgment and optimal physician-patient communication will always remain at the center of good medical care.

For centuries, health providers have focused on the prevention, diagnosis and treatment of disease. This time-honored paradigm has generated phenomenal advances in medicine, especially during the last 60 years. It has also created a bit of an image problem for providers. That’s because the paradigm encourages consumers to perceive health care as a negative good; an economic term describing a bundle of products and services that we use because we must, not because we want to. Recent trends towards empowered consumers are a symptom of this problem more than a solution to it, as I described here.

Recently, the concept of Positive Health has emerged as a possible antidote for the malaise.

Pioneered by University of Pennsylvania psychologist Martin Seligman, Positive Health encourages us to identify and promote positive health assets—which Seligman describes as strengths that contribute to a healthier, more fulfilling life and yes, improved life expectancy as well. According to Seligman, “people desire well-being in its own right and they desire it above and beyond the relief of their suffering.”

Proponents of Positive Health have proposed that several social and functional factors are positive health assets. These include optimism, connectedness, a stable marriage and so forth. Scientists, often supported by the Robert Wood Johnson’s Pioneer Program, have begun studying these proposals. Their results have been compelling to say the least.

This post is the first of a series on Positive Health. In each post, I’ll review scientific studies of the matter and as the series unfolds, I’ll  discuss the relationship between this emerging paradigm and the traditional disease-oriented paradigm favored by today’s health providers.

Heart Health Linked to Satisfaction with Life
Most people know that negative psychological states like stress, anxiety and depression are linked to poor health outcomes, including a slew of adverse cardiac outcomes. Does it follow that a state of emotional and cognitive well-being can have a protective effect on cardiovascular health?

To answer this question, Harvard’s Julia Boehm and colleagues reviewed data from the Whitehall II study, which involved nearly 8,000 British civil servants. As part of that study, each participant had assessed his or her satisfaction with several dimensions of life experience including leisure activities, standard of living, job, health, family life, sex life, marital or love relationships and overall feelings about themselves as a person. Participants also provided yes/no answers regarding negative aspects of their lives including the presence of depression, anxiety and so forth.

The Whitehall II study also collected information regarding age, gender and traditional cardiovascular risk factors like cigarette smoking, diabetes and hypertension,. It assessed the incidence of coronary heart disease using three measures, presence of angina, documented heart attacks, and deaths from coronary disease during a 5-year follow-up period after the information had been collected.

Boehm’s team examined these data and found a clear, indirect relationship between satisfaction with each life domain and the risk of coronary heart disease: people reporting higher satisfaction had lower cardiac risk. Specifically, subjects in the highest tertile of satisfaction had a 26% lower risk of coronary events, and those in the middle third had a 20% reduced risk compared with those reporting the lowest levels of life satisfaction.

These trends reached statistical significance in 4 of the 7 dimensions: satisfaction with job, family life, sex life and overall feelings about themselves, and they persisted after controlling for age, gender, health behaviors, blood pressure, and metabolic functioning.

What to Make of This?
The study provides strong, though narrowly focused support for Seligman’s theories about Positive Health. Being satisfied with specific life domains—especially the 4 mentioned above—is associated with lower risk of coronary heart disease, even after accounting for traditional cardiovascular risk factors. If these findings can be validated, scientists should follow-up with studies to determine whether interventions designed to enhance life satisfaction can reduce cardiovascular risk.

Of note, the beneficial effects in this study were localized to angina, one of 3 outcome measures examined by Boehm’s group. There was no association between life satisfaction and the so-called ‘hard’ cardiovascular outcomes like heart attacks and cardiovascular deaths. Reporting bias could explain these findings: people that have favorable feelings about their lives might be more likely to report favorably about their health or have a higher tolerance for pain.

On the other hand, subjects in the Whitehall II study were relatively young (mean age = 50). In the natural history of coronary artery disease, angina frequently becomes manifest before heart attacks and death from cardiovascular causes. Participants in the study were followed for a fairly short time, only 5 years. It’s possible that longer follow-up would have revealed higher incidence of ‘hard’ cardiovascular outcomes.

It’s also possible that–since nearly all patients who sustain heart attacks have coronary artery disease, but only some with atherosclerosis sustain a heart attack—life satisfaction might be associated with increased risk of atherosclerosis but not with the specific factors that predispose to thrombotic events, plaque rupture and other antecedent events to heart attacks.

Further studies are required to sort through these alternative explanations.