Telehealth Treatment of Anxiety in Patients With Low-Risk Chest Pain in the Emergency Department: The PACER Randomized Clinical Trial.

Abstract

Importance: Chest pain is a leading reason for emergency department (ED) visits, with most cases classified as low-risk chest pain (LRCP) after excluding acute coronary syndrome. Many patients with LRCP experience undiagnosed or undertreated anxiety.

Objective: To determine if 2 types of telehealth-delivered cognitive behavioral therapy (CBT) interventions were superior to primary care referral for patients with LRCP and anxiety.

Design, setting, and participants: The Patient-Centered Treatment of Anxiety After Low-Risk Chest Pain in the Emergency Room (PACER) trial was a randomized, 3-group comparative effectiveness trial conducted across 6 university health systems EDs that enrolled adults with LRCP who were discharged from the ED and had at least moderate anxiety (Generalized Anxiety Disorder-7 [GAD-7] score ≥8 or Patient Health Questionnaire [PHQ] panic screener score ≥2) from April 2021 to July 2024 (12-month follow-up was completed by July 2025). Data analysis began in July 2025 and was completed by January 2026.

Interventions: All 3 groups received psychoeducation. The 3 interventions compared were (1) recommended primary care follow-up, (2) peer-supported internet-based CBT (iCBT), and (3) therapist-delivered CBT via telehealth.

Main outcomes and measures: The primary outcome was change over 12 months in the GAD-7 anxiety score. Secondary outcomes included global anxiety improvement, PHQ-8 depression scores, PHQ-14 somatization scores, and Sheehan Disability Scale scores. Outcomes were assessed at 3, 6, 9, and 12 months.

Results: A total of 375 patients were enrolled (265 female individuals [70.7%] and 109 male individuals [29.1%]; 125 Black individuals [33.3%], 28 Hispanic individuals [7.5%], 226 White individuals [60.3%], and 22 individuals [5.9%] of other race; mean [SD] age, 39.9 [13.1] years). Adjusted mean improvement in GAD-7 over 12 months was significant within all arms (4.32, 5.54, and 5.13 points in the primary care referral, peer-supported iCBT, and therapist-delivered CBT groups, respectively, for which the baseline SD pooled over groups that was used to calculate all effect sizes was 4.83). Improvement with peer-supported iCBT was 1.22 points greater (95% CI, 0.01-2.43; effect size = 0.25) than primary care referral, and this effect was strongest (2.8 points) among patients with severe anxiety. Depression, somatization, and disability improved moderately within groups, with no significant between-group differences. Odds of patient-reported global anxiety improvement were 3 times higher in the 2 CBT groups compared with primary care referral. Higher engagement was associated with greater anxiety reduction. Therapeutic alliance and program satisfaction were high in both CBT groups.

Conclusions and relevance: The results of this randomized clinical trial suggest that peer-supported iCBT significantly reduces anxiety in ED patients with LRCP and elevated anxiety, with the greatest improvement occurring in patients with severe anxiety.

Trial registration: ClinicalTrials.gov Identifier: NCT04811521.