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More than 50 % of patients seeking hospital care because of chest pain are diagnosed as having “non-cardiac” symptoms [1, 2]. Many patients are discharged without knowing the cause of their chest pain [3, 4]. Patients with noncardiac chest pain experience psychological distress [5, 6] and use healthcare resources to a great extent, leading to high healthcare costs [7–11]. Despite reassurance [12], many patients think they have an undetected cardiac disease and avoid activities that they believe might be harmful to the heart [13, 14]. Cardiac anxiety is common in patients with recurrent non-cardiac chest pain [6], leading to a vicious cycle, as it leads to maintenance of both anxiety and pain and secondary avoidance of physical activity [15, 16]. Targeting cardiac anxiety with psychological interventions might break the vicious circle and improve patient outcomes. Patients need to evaluate the way they perceive and handle their chest pain; this can be achieved using cognitive behavioural therapy (CBT) [17]. There is strong support for face-to-face CBT in the treatment of mild and moderately severe states of anxiety and depressive disorders [18–20] and non-cardiac chest pain [21, 22]. Previous face-to-face CBT studies [12, 23–26] have shown positive effects on chest pain frequency, activity avoidance, anxiety, and depression among patients with non-cardiac chest pain. Face-to-face CBT can be effective when delivered by experts, but it is time-consuming [27, 28] and therefore not easy to provide to everyone. Internet-delivered CBT seems as a good alternative since it is cheaper, is not time dependent, and requires less therapist involvement [28], and could therefore be given to more patients. Therapist-guided Internet-delivered CBT does not differ from face-to-face treatment with regard to treatment effects [28–30], regardless of the background of the therapist guiding the Internet-delivered CBT [18, 31–33]. As concluded by Sharp et al. [34], Internet-delivered CBT might be a means to increase access to psychological treatment to patients with different chronic somatic conditions, although more research is needed to establish the feasibility and efficacy of Internet-delivered CBT for such populations. However, no Internet-delivered CBT programs have been tested in patients with non-cardiac chest pain. Our hypothesis was that a guided Internetdelivered CBT program targeting cardiac anxiety can help patients modify their beliefs about chest pain, change their cognitive and behavioural strategies, and give them tools to handle their chest pain. Furthermore, a four-week treatment would be preferred by the patients and easier to implement in the healthcare settings than a longer faceto-face treatment. The purpose of the study was to test the feasibility of a short guided Internet-delivered CBT program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care.


Mary MacKillop Institute for Health Research

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© 2016 Mourad et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated

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