1. Internet-delivered cognitive behavioral (iCBT) therapy reduced cardiac anxiety in people with non-cardiac chest pains but was not superior to psychoeducation.
2. iCBT reduced the frequency of chest pains in people with non-cardiac chest pains.

Evidence Rating Level: 1 (Excellent)

Chest pain is one of the most concerning presenting symptoms in the clinical setting. The differential diagnosis of chest pain includes highly concerning life-threatening diseases from pulmonary embolism to myocardial infarction. Fifty percent of chest pain presentations to the emergency department, however, are typically non-cardiac chest pains (NCCP). The association of chest pains with heart disease makes symptoms very distressing to patients. This is termed cardiac anxiety (CAx). CAx negatively impacts quality of life and leads to an increase in chest pain frequency. Cognitive behavioral therapy (CBT) is the treatment of choice for CAx. The effectiveness of internet-delivered CBT (iCBT) on CAx has not been fully investigated.

This nonrandomized control trial investigated the effectiveness of nurse-led iCBT on the treatment of CAx compared to psychoeducation in Sweden. There were 109 individuals with NCCP that were randomized to the two treatment arms; 54 in the iCBT group, and 55 in the psychoeducation group. Swedish-speaking participants over the age of 18, with an NCCP complaint in the last 6 months, diagnosed CAx (score >24 on cardiac anxiety questionnaire (CAQ)), and who had access to a computer were included. Participants who did not meet these criteria were excluded. Participants received 5 weeks of either iCBT or psychoeducation depending on their treatment group. CAx was assessed after the study, then at 3-, 6-, and 12-months post-intervention. The primary outcome measured was CAx using the CAQ. Secondary outcomes included fear of bodily sensations, depressive symptoms, and chest pain frequency.

Concerning the primary outcome, while iCBT did show success at reducing CAx, it was not superior to psychoeducation alone. Concerning secondary outcomes, iCBT did not show superiority to psychoeducation at reducing fear of bodily sensations or depressive symptoms. iCBT was, however, statistically significant in reducing chest pain frequency. A limitation of this study is that researchers did not consider further healthcare utilization a participant might have taken in working up their chest pain. For example, if an individual with NCCP utilized further medical investigation to reassure them their chest pain was not cardiac related, their anxiety would be less than an individual who only adhered to the treatment arms utilized in the study. Nevertheless, iCBT’s ability to reduce CAx in general and reduce chest pain frequency is a valuable finding. Increased frequency of chest pains leads to further utilization of healthcare by patients impacting their daily activities and quality of life overall. This study shows iCBT is a viable, and convenient option for the treatment of CAx.

Click here to read this study in BMC Psychiatry

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