A recent study published in the Journal of the American Heart Association provides evidence that an internet based mental health program can help reduce stress and anxiety in people recovering from certain types of heart events. The research suggests that online cognitive behavioral therapy is particularly beneficial for patients who experience a specific stress induced heart condition known as Takotsubo syndrome. These findings point to a promising way to offer tailored psychological support to patients who might otherwise lack dedicated rehabilitation options.
About nine percent of all patients who appear to have a typical heart attack are later found to have open, unblocked blood vessels. This medical condition is known as a myocardial infarction with nonobstructive coronary arteries. It accounts for up to ten percent of all heart attacks, and around sixty percent of those affected are women.
Another two to three percent of patients presenting with heart attack symptoms are diagnosed with Takotsubo syndrome. Historically considered a subcategory of the unblocked artery condition, Takotsubo is now recognized separately because it is not caused by a lack of oxygen in the heart muscle. The condition was first identified in Japan, named for the resemblance between the affected left ventricle and an octopus trap, or “takotsubo.”
Takotsubo syndrome is often triggered by extreme mental or physical stress, causing the heart muscle to suddenly weaken. Patients in the study reported their illness was preceded by stressful events like a death in the family, shocking occurrences, or workplace conflicts. Ninety percent of those affected by this specific syndrome are postmenopausal women. Both conditions mimic a traditional heart attack, presenting with sudden chest pain and shortness of breath.
Because these conditions lack the blocked arteries seen in standard heart disease, patients often face diagnostic uncertainty. There is currently a lack of evidence based medical guidelines tailored to their specific recovery needs. As a result of this uncertainty, people recovering from these heart issues tend to experience high levels of distress.
“This is a group that has gone largely unnoticed, as men are over-represented in the standard statistics on heart disease. But women are also affected, albeit in different ways. That is why we must develop new treatment methods for this group as well,” said Philip Leissner, a psychologist at Uppsala University and the study’s first author.
Cognitive behavioral therapy is a common type of talk therapy that helps people identify and change negative thought patterns. Providing this therapy over the internet offers a flexible and cost effective way to reach more patients. The authors wanted to see if an internet delivered therapy program designed specifically for this patient population could ease their psychological burden.
To test this idea, the scientists set up a randomized controlled trial at seven emergency hospitals in Sweden, including facilities in Stockholm, Örebro, and Östersund. They recruited eighty eight patients who had recently been admitted for either of the two unblocked heart attack conditions. The patients needed to show elevated symptoms of stress or anxiety on initial screening tests to be included in the trial.
The study group was predominantly female, making up ninety one percent of the participants, with an average age of sixty three years. This high percentage of women reflects both the nature of the specific heart conditions and the fact that women are generally more likely to participate in psychological treatment. The researchers randomly split the patients into two separate groups. Forty five individuals were assigned to receive the internet based therapy right away.
The remaining forty three patients were placed on a wait list to act as a control group. The control group received standard medical care, which included routine doctor and nurse follow up appointments. The treatment group gained access to an online program that was developed in collaboration with patients who had personal experience with these diagnoses. The therapy lasted between seven and nine weeks, tailored to individual patient needs.
The therapy program involved reading educational information, setting treatment goals, and practicing stress management techniques. Patients also worked on active problem solving, relaxation exercises, and gradual exposure to situations that caused them fear. A licensed psychologist monitored their progress and provided written feedback once a week through a secure online portal.
In addition to the online modules, patients were offered two brief telephone consultations with their psychologist. These conversations allowed them to discuss their treatment plans, manage expectations, and solve any practical technical issues. The researchers used several standard psychological questionnaires to measure the mental well being of the participants.
The Perceived Stress Scale, a fourteen item survey, was used to gauge how unpredictable and overloaded the patients felt their lives were over the past month. The Hospital Anxiety and Depression Scale was used to measure the intensity of their anxiety and depression symptoms. Other specialized surveys measured heart focused anxiety and symptoms of psychological trauma.
The primary goal of the study was to see if the therapy could bring both stress and anxiety scores back down to normal, healthy levels at the exact same time. The results indicated that the treatment group had a higher number of patients reach this combined goal compared to the control group. About fifty two percent of the treated patients achieved normal levels on both scales, compared to about thirty eight percent of the control group.
“We can see that our treatment, which consists of an internet-based CBT program designed to manage stress and anxiety, reduces the symptoms. The reduction is significant and is in line with the results typically seen in psychological treatments. Furthermore, very few people dropped out, which suggests that the treatment was appreciated,” Leissner said.
When looking at the mental health symptoms separately, the therapy showed a more defined therapeutic benefit. The scientists found that a significantly higher proportion of patients in the treatment group returned to normal anxiety levels compared to those receiving standard care. The online therapy program also successfully reduced the overall severity of perceived stress and trauma symptoms across the treatment group.
“Both symptoms of stress and anxiety decreased as a result of the treatment. What we observed, above all, was that patients reacted less negatively to stress, rather than that they felt able to manage stressful situations in their daily lives,” Leissner said.
He explained that some environmental stressors cannot be easily changed by the patient. “We interpret this to mean that there are factors in their daily lives that they cannot do very much about, such as the fact that they have developed this illness. But at least they got better at dealing with the emotions that arise,” Leissner said.
The researchers also noticed a difference in how the two distinct patient groups responded to the therapy. Patients diagnosed with Takotsubo syndrome seemed to benefit much more from the online program than those with nonobstructive heart attacks. Among the patients with the stress induced Takotsubo condition, sixty seven percent in the treatment group reached completely normal stress and anxiety levels. In contrast, only twenty five percent of the Takotsubo patients in the control group achieved this same normalization.
“These patients benefited greatly from the treatment. One explanation could be that there were more patients with takotsubo syndrome in the group that designed the treatment. But it could also be because these individuals have a greater need of psychological treatment, that they may have been suffering from stress and poor health for some time and really need help,” Leissner said.
While the study provides evidence for the benefits of online mental health support, there are a few limitations to keep in mind. The primary study outcome combined two separate psychological goals into one single measure. This statistical choice may have made it mathematically harder to prove a definitive, overarching success. Setting such a high standard for complete normalization of both conditions might have masked some of the incremental improvements the patients actually experienced.
Grouping two distinct heart conditions into a single study may have also complicated the overall findings. Nonobstructive heart attacks have various physical underlying causes, while Takotsubo syndrome has a more specific, stress related emotional profile. This fundamental medical difference might explain why the Takotsubo group responded so much better to the psychological intervention.
The researchers plan to continue refining their online therapy model to determine exactly which components were most effective. Future research should likely separate these two patient populations to better understand their unique therapeutic needs. Better powered trials with larger sample sizes could help confirm these initial positive findings regarding online therapy. Continued work in this area suggests a promising path for integrating targeted mental health care into routine cardiology practices.
The study, “Randomized Controlled Trial of Internet‐Delivered Cognitive Behavioral Therapy After Myocardial Infarction With Nonobstructive Coronary Arteries or Takotsubo Syndrome,” was authored by Philip Leissner, Runa Sundelin, Elisabet Rondung, Sophia Humphries, Claes Held, Jonas Spaak, Anders Ulvenstam, Anna Nordenskjöld, Fredrika Norlund, Lena Kövamees, Patrik Lyngå, Erik Olsson, and Per Tornvall.
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