**7. Quality of life**

after 4 years [35]. SRH was reported as an independent predictor of long term mortality in older women after myocardial infarction. Patients dissatisfied with their general health status were at more than six times higher risk of mortality than the satisfied ones [36]. There are only few data available on the link between CABG and SRH. Oxlad et al. investigated consecutive elective CABG patients on self-report measures including optimism, illness representations, self-rated health, social support, coping methods, depression, anxiety and post-traumatic stress disorder. Poor pre-operative psychological functioning was the strongest psychological

Negative emotional states (e.g., depression, anxiety) are proven risk factors for cardiovascular disease; however, much less is known about the association between positive emotional states (e.g., happiness and optimism) and cardiovascular health. Steptoe et al. have suggested that positive emotions may have direct and beneficial effects on physiological processes including those involving the neuroendocrine, inflammatory, immunological and cardiovascular sys‐ tems [38]. The association between positive psychological well-being and mortality could be mediated in part via behavioural pathways. For example positive dispositions are related to predictors of prolonged survival, such as not smoking, exercising regularly, reduced alcohol consumption, and better sleep quality. Psychologically balanced persons might have increased adherence to medical regimens because inverse associations between adherence and depres‐ sion have been described. However, the protective effect of positive emotions on mortality in healthy population studies persisted even after fully controlling for behavioural covariates, suggesting that other pathways may also be involved. Direct physiological pathways might also contribute to associations. Positive psychological well-being could alter people's disease susceptibility via the attenuation of sympathetic nervous system activity and the enhancement ofparasympatheticactivation.Positiveaffectsmayreducestress-inducedelevationsofinflamma‐ toryandcoagulationfactors,suchasfibrinogenandinterleukin-6,whicharecrucialincardiovas‐ culardisease,andreducevulnerabilitytoinfectiousillness.Positivepsychologicalwell-beingwas associated with reduced cardiovascular mortality in healthy population studies, with a near significant effect in patients with established cardiovascular disease [39]. In one of prospective epidemiological cohort studies participants with greater emotional vitality were at markedly reduced risk for CHD, and this effect remained significant after controlling for medical and psychosocial factors [40]. Optimism was associated with recovery from CABG surgery within 6 months [41]. Post hoc analysis of previous data showed that among depressed post-CABG patients, optimists responded to depression treatment at higher rates. Independent of depres‐

risk factor for adverse psychological functioning six months post-operatively [37].

sion, optimists were less likely to be rehospitalized by 8 months after CABG [42].

One of the important determinants of quality of life is taking part in psychologically mean‐ ingful activity. Illnesses, mostly chronic ones interfere with valued activities. Illness intrusive‐

**5. Happiness**

474 Artery Bypass

**6. Illness intrusiveness**

With aging of the population and sophisticated health care technologies the number of patients with chronic diseases has extremely increased. As a result, improving the daily functioning and quality of life of the chronically ill has become an important goal of medical and surgical interventions. Therefore assessing the quality of life has been brought into the limelight [45]. On the other hand, predictive value of quality of life on survival and other outcomes of cardiac surgery has been also studied. In a prospective study of 6305 patients who underwent isolated coronary artery bypass the overall functional health-related quality of life improved after recovery from cardiac surgery. Reduced long-term survival following cardiac surgery even after adjustment for known risk factors associated with survival after cardiac surgery was associated with lower functional health related quality of life beyond the posthospital recovery phase. The degree of functional recovery was directly related to subsequent survival [46]. In a prospective cohort study the preoperative quality of life was an independent predictor of 6 month mortality following CABG even after adjusting for traditional risk factors. The magni‐ tude of the effect (39% increase in risk for a small difference in quality of life score) was clinically important, and it is a non-invasive, easily available tool for clinicians [47].
