JMIR Publications

ABSTRACT

Background:

Cardiovascular (CV) events such as a myocardial infarction with non-obstructive coronary arteries (MINOCA) or takotsubo syndrome (TS) are associated with heightened levels of stress and anxiety. There are currently no established treatment guidelines for these conditions, but emerging research indicates that internet-based cognitive behavior therapy (ICBT) is effective in the short-term for reducing these symptoms. However, the long-term stability of effects is unknown, as well as the importance of timing of the intervention.

Objective:

This paper aims to investigate the stability of effects achieved by ICBT after MINOCA or TS for common mental health symptoms, as well as to compare the difference in effect between early and late initiation of the intervention.

Methods:

This was a parallel, multicenter, randomized controlled trial of ICBT on symptoms of stress and anxiety. The ICBT intervention was a guided, 7–9-week written program, where completion of at least 5/9 steps was considered a minimum dose. Participants were included if they reported elevated stress (Perceived stress scale, 14 items [PSS-14] > 24) or anxiety (Hospital anxiety and depression scale, anxiety subscale [HADS-A] > 7) and were randomized (1:1) to either early intervention group (EIG; immediately after randomization) or late intervention group (LIG; 10-12 weeks after randomization). Mental health outcomes were assessed using PSS-14, HADS, cardiac anxiety questionnaire [CAQ], and impact of event scale [IES]. Outcome data was collected at three follow-up time points: 10-12 (1), 20-22 (2), and 50-52 (3) weeks after randomization. This paper reports results from follow-up 2 and 3. Data was analyzed by the intention-to-treat principle, using linear mixed models, assuming data missing at random.

Results:

Eighty-eight participants were randomized (EIG: 45; LIG: 43). The response rate at follow-up 2 was 81% and at follow-up 3 was 73%. Eighty-seven percent completed the minimum dose in the EIG, and 51% in the LIG. Intervention effects achieved in the EIG at follow-up 1 remained stable over time. The average trend was lower levels of stress and anxiety in the EIG compared with the LIG, but no differences were statistically significant. Regarding symptoms of post-traumatic stress, the EIG reported significantly lower levels than the LIG, at follow-up 2 (-2.32, 95% CI: -4.42, -0.21, p=0.03).

Conclusions:

Short-term effects achieved by ICBT after MINOCA or TS for symptoms of stress and anxiety were stable over time and there was little evidence suggesting a difference in effect between early or late initiation of treatment. However, patients in the EIG completed the treatment to a higher degree and reported superior treatment effects on symptoms of post-traumatic stress. These novel findings are important for informing care after a MINOCA or TS, but more research is needed before firm conclusions can be drawn. Clinical Trial: clinicaltrials.gov NCT04178434