Recent research published in American Heart Association Journal provides evidence that internet-based mental health programs can help reduce stress and anxiety in people recovering from certain types of cardiac events. This study suggests that online cognitive behavioral therapy may be particularly beneficial for patients experiencing a particular type of stress-induced heart disease known as Takotsubo syndrome. These findings demonstrate a promising way to provide customized psychological support to patients who may lack dedicated rehabilitation options.
About 9 percent of all patients who appear to have a typical heart attack are later found to have open, unblocked blood vessels. This condition is known as myocardial infarction due to non-obstructed coronary artery. It accounts for up to 10 percent of all heart attacks and approximately 60 percent of those affected are women.
An additional 2 to 3 percent of patients who exhibit heart attack symptoms are diagnosed with Takotsubo syndrome. Historically considered a subcategory of nonobstructive artery disease, octopus is now recognized separately because it is not caused by a lack of oxygen in the heart muscle. This condition was first identified in Japan and was named for the resemblance of the affected left ventricle to an octopus pot (“takotsubo”).
Takotsubo syndrome is often caused by extreme mental or physical stress, which causes the heart muscle to suddenly weaken. Patients in the study reported that their illness had been preceded by stressful events, such as a death in the family, a traumatic event, or a conflict at work. 90% of people affected by this particular syndrome are postmenopausal women. Symptoms of both are similar to a traditional heart attack, including sudden chest pain and shortness of breath.
Patients often face diagnostic uncertainty because these conditions do not have the blocked arteries seen in standard heart disease. Currently, there is a lack of evidence-based medical guidelines tailored to their specific recovery needs. As a result of this uncertainty, people recovering from these heart problems tend to experience high levels of distress.
“This group receives little attention because men are overrepresented in standard statistics on heart disease. However, women are also affected, albeit in different ways, which is why we need to develop new treatments for this group as well,” said the study’s lead author, psychologist Philipp Reissner from Uppsala University.
Cognitive behavioral therapy is a common type of talk therapy that helps people identify and change negative thinking patterns. Delivering this treatment via the Internet provides a flexible and cost-effective way to reach more patients. The authors wanted to see if an internet-delivered treatment program designed specifically for this patient population could reduce their psychological burden.
To test this idea, scientists conducted a randomized controlled trial at seven acute care hospitals in Sweden, including facilities in Stockholm, Örebro, and Östersund. They recruited 88 patients recently hospitalized with one of two unblocked heart attack conditions. To participate in the trial, patients had to show elevated symptoms of stress or anxiety on an initial screening test.
The study group was predominantly female, accounting for 91 percent of the participants, with an average age of 63 years. This higher proportion of women reflects both the nature of the specific heart disease and the fact that women are generally more likely to participate in psychological treatment. The researchers randomly divided the patients into two groups. Forty-five people were immediately assigned to receive Internet-based treatment.
The remaining 43 patients were placed on the waiting list as a control group. The control group received standard medical care, including regular doctor and nurse follow-up appointments. The treatment group had access to an online program developed in collaboration with patients who had personal experience with these diagnoses. Treatment lasted 7 to 9 weeks depending on individual patient needs.
The treatment program included reading educational information, setting treatment goals, and practicing stress management techniques. Patients also engaged in active problem solving, relaxation training, and gradual exposure to fear-inducing situations. A licensed psychologist monitored their progress and provided written feedback once a week through a secure online portal.
In addition to the online module, patients were offered two short telephone consultations with a psychologist. These conversations allowed us to discuss treatment plans, manage expectations, and resolve practical technical issues. The researchers used several standard psychological questionnaires to measure the participants’ mental health.
The Perceived Stress Scale, a 14-item survey, was used to measure how unpredictable and overloaded patients felt their lives were over the past month. The Hospital Anxiety and Depression Scale was used to measure the intensity of anxiety and depression symptoms. Other specialized surveys measured symptoms of heart-focused anxiety and psychological trauma.
The main goal of this study was to see if this therapy could simultaneously return both stress and anxiety scores to normal, healthy levels. Results showed that a greater number of patients achieved this composite goal in the treatment group compared to the control group. About 52 percent of treated patients achieved normal levels on both scales, compared with about 38 percent of the control group.
“We find that our treatment, which consists of an internet-based CBT program designed to manage stress and anxiety, reduces symptoms. This reduction is significant and consistent with results typically seen in psychotherapy. Additionally, there were very few dropouts, suggesting that the treatment was evaluated,” Riesner said.
When looking at mental health symptoms individually, the therapy showed a clearer therapeutic effect. The scientists found that a significantly higher proportion of patients in the treatment group returned to normal anxiety levels compared to those receiving standard treatment. The online treatment program was also successful in reducing the overall severity of stress and trauma symptoms perceived across the treatment group.
“As a result of treatment, symptoms of both stress and anxiety were reduced. What we observed, above all, was that patients had fewer negative reactions to stress, rather than feeling better able to cope with stressful situations in their daily lives,” Reisner said.
He explained that some environmental stressors cannot be easily changed by patients. “We interpret this to mean that there are factors in their daily lives that they have less control over, such as the fact that they developed this disease, but at least they are now better able to cope with the emotions that arise,” Riesner said.
The researchers also noticed differences in how the two different patient groups responded to the treatment. Patients diagnosed with Takotsubo syndrome appear to benefit much more from online programs than patients with non-obstructive heart attacks. Among patients with stress-induced takotsubo, 67% of the treatment group achieved completely normal stress and anxiety levels. In contrast, only 25% of Takotsubo patients in the control group achieved this same normalization.
“These patients benefited greatly from the treatment. A possible explanation could be that the group for which the treatment was designed had more people with Takotsubo syndrome. But these people also have a higher need for psychological treatment, have been suffering from stress and poor health for some time, and may really need help,” Riesner said.
Although this study provides evidence of the benefits of online mental health support, there are some limitations to keep in mind. The main finding was the combination of two separate psychological goals into one single measure. This statistical choice may have made it mathematically difficult to prove definitive and comprehensive success. Setting such high standards for complete normalization of both conditions may mask some of the gradual improvement that patients actually experience.
Grouping two different heart conditions into one study may also have complicated the overall findings. While non-obstructive heart attacks can have a variety of physical causes, Takotsubo syndrome has a more specific stress-related emotional profile. This fundamental medical difference may explain why the Takotsubo group responded so well to psychological intervention.
Researchers plan to continue refining the online treatment model to determine exactly which components were most effective. Future research will likely need to separate these two patient populations to better understand their unique treatment needs. More powerful trials with larger sample sizes could help confirm these early positive findings regarding online treatment. Continued research in this area suggests a promising path to integrating targeted mental health care into routine cardiac care.
The study, “Randomized controlled trial of internet-based cognitive behavioral therapy after myocardial infarction due to non-obstructed coronary artery or Takotsubo syndrome,” was authored by Philip Leissner, Runa Sundelin, Elisabet Rondung, Sophia Humphries, Claes Held, Jonas Spaak, Anders Ulvenstam, Anna Nordenskjöld, and Fredrika. Norlund, Lena Kövamees, Patrik Lyngå, Erik Olsson, and Per Tornvall.
