This study examined whether satisfaction with specific life domains was prospectively associated with incident CHD after controlling for conventional risk factors and ill-being. In minimally adjusted and multivariate-adjusted models, satisfaction averaged across seven life domains was significantly associated with a modest reduced risk of total CHD. The size of the effect was comparable for both men and women, although fewer case counts attenuated statistical power. A statistically significant dose–response effect existed such that individuals reporting the most satisfaction had the greatest risk reduction compared with individuals reporting moderate and low satisfaction levels. Effects seem to be driven largely by a statistically significant association with definite angina. Phase 1 global life satisfaction was not significantly associated with CHD in secondary analyses.
Limited work has examined the association between CHD and life satisfaction. Moreover, well-being has rarely been measured by combining domain-specific evaluations. It is unclear exactly why Phase 1 global satisfaction was unrelated to CHD in secondary analyses. However, the moderate association between global satisfaction and mean domain satisfaction suggests that these measures may capture something different, and that satisfaction within particular life domains may be especially relevant for coronary outcomes. Furthermore, positive affect has not consistently been associated with incident CHD.4,9
For example, research with the Whitehall II cohort reported that positive affect was unrelated to CHD over 10 years, although it is unclear whether or not it was associated with CHD across 5 years or with definite angina.9
The seven specific life domains shared similar distributions and were moderately to strongly interrelated (Pearson r
s ranged from 0.27 to 0.73), but only four life domains were significantly associated with CHD-related outcomes—job, family, sexual, and self satisfaction. Prior research indicates that work and love are central to human functioning,25
which suggests categories that may be particularly relevant for cardiovascular health. Indeed, job satisfaction, family satisfaction, and sexual satisfaction fall within the categories of work and love. However, this cannot fully account for why satisfaction with one's marital/love relationship was not significantly associated with reduced CHD risk, or why satisfaction with one's self was.
Satisfaction was not significantly associated with ‘hard' outcomes of coronary death and MI. Instead, the association between satisfaction and total CHD was driven primarily by definite angina. Other research on psychological well-being has not routinely separated ‘hard' outcomes from angina, although the few studies that have done so report inconsistent results. For example, in one prospective study of older women, the association between optimism and CHD was stronger when MI was considered alone than in a composite of angina, angioplasty, and coronary artery bypass grafting.5
In an investigation of ageing men, the magnitude of association between optimism and fatal CHD, non-fatal MI, and angina (separately) was similar.18
Finally, in work with other psychological constructs, stress was associated with angina but not ‘objective' cardiovascular-related outcomes.26
Given inconsistencies in past work, how can stronger findings for angina be reconciled? One explanation involves a reporting bias. Angina is often established through self-reports of chest pain. Individuals with favourable views of their lives may be more likely to report favourable views of their health and have higher pain tolerance.27–29
All self-reported instances of angina were confirmed clinically in the present investigation, but the extent of misclassification due to undiagnosed angina was probably dependent on self-report, which introduces a potential reporting bias according to one's psychological outlook. Previous work, however, suggests that angina is a strong predictor of future cardiovascular events.30,31
Other explanations may relate to the relatively young age of the present sample (average of 50 years) and how that coincides with the course of CHD. Because angina may be a sign or symptom of underlying atherosclerosis—or, in other words, a precursor to MI—it is feasible that in the age group we studied and for the relatively short period in which we studied them, angina occurred more frequently than fatal CHD/non-fatal MI. Indeed, there were more cases of angina than coronary death or MI. Perhaps findings for fatal CHD/non-fatal MI would more closely resemble those for angina if participants had been followed for a longer period of time to capture a more complete trajectory of CHD. Furthermore, as all patients with MI have coronary atherosclerosis but only a few with atherosclerosis develop MI, satisfaction might be related to overall risk of atherosclerosis but not with the unique factors that predispose individuals to plaque rupture or MI.
Use of the Whitehall II cohort may limit generalizability because participants were employed and relatively healthy. Other limitations concern the measurement of life satisfaction. Analyses may have been overly simplistic by separately averaging domain satisfactions and asking about general life satisfaction. Integrating the two approaches may be more informative than either approach on its own.8
Additionally, averaging domain satisfactions may not have adequately represented life satisfaction. Instead, a more complex relationship may exist whereby some domains weigh more heavily in overall judgements of life satisfaction13
or a balance of satisfaction across some critical set of domains may better reflect overall life satisfaction.32
This study has numerous strengths, including a large and well-characterized cohort, prospectively measured well-being, detailed follow-up of objectively assessed CHD, and clinically assessed CHD risk factors. The current investigation also evaluated whether conventional covariates related to health behaviours or cardiovascular and metabolic functioning might explain the observed association between satisfaction and angina. Effects were not attenuated when these covariates were added, which either suggests that the relationship is largely a function of self-report bias or that other mechanisms may be important to consider. In fact, other investigations of psychological factors and CHD frequently find that conventional risk factors explain little of the observed associations.33
Taken together, this research indicates that being satisfied with specific life domains—in particular, one's job, family, sex life, and self—is associated with a reduction in incident CHD independently of traditional risk factors and ill-being, but these findings are primarily due to an association with angina. Additional research is needed to determine whether there is truly an association with specific forms of CHD, or if this is primarily an artifact of self-report bias. Disentangling these possibilities should be considered of high clinical relevance. A more definitive understanding may help determine whether interventions to enhance life satisfaction in specific domains could improve CHD outcomes in high-risk individuals. Moreover, findings may suggest that assessing the psychological profile of patients with angina adds predictive value for evaluating risk of subsequent CHD events.