Telehealth Treatment of Anxiety in Patients With Low-Risk Chest Pain in the Emergency Department

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