A randomized trial found peer-supported online cognitive behavioral therapy helped ease anxiety after low-risk chest pain, particularly for patients with severe anxiety.
Study: Telehealth Treatment of Anxiety in Patients With Low-Risk Chest Pain in the Emergency Department. Image credit: Studio Romantic/Shutterstock.com
A recent JAMA Internal Medicine study examined the impact of telehealth-delivered cognitive behavioral therapy (CBT) interventions in patients with low-risk chest pain and anxiety.
Low-risk chest pain: prevalence and clinical impact
Chest pain is the second leading cause of emergency department visits in the United States, with more than 8 million cases annually. Although clinical evaluation primarily focuses on acute coronary syndrome (ACS), nearly 80% of patients are found not to have cardiac or cardiopulmonary emergencies. These patients typically receive a diagnosis of low-risk chest pain (LRCP), characterized by chest pain in the absence of acute coronary stenosis.
The economic burden of LRCP is considerable, with evaluation costs reaching up to $8 billion annually. Anxiety affects up to 55% of LRCP patients, yet remains undiagnosed in nearly 90% of cases. Importantly, 50% to 80% of these patients develop persistent chest pain and continue to seek medical attention despite negative cardiac evaluations and clinical reassurance.
Untreated anxiety in this population leads to increased health care utilization and reduced quality of life. Anxiety and its physiological effects may also contribute to systemic inflammation. Accordingly, recent guidelines advocate for the screening and management of anxiety and depression in patients with recurrent LRCP.
CBT has proven effective for anxiety and related psychological comorbidities, whether delivered in person, via telehealth, or through guided internet-based CBT (iCBT). Notably, iCBT with nonprofessional guided support has shown noninferiority to therapist-guided support for anxiety and depression.
Despite these promising findings, a review of 17 trials involving 1006 LRCP patients highlighted significant research gaps: most studies were small, methodologically limited, and lacked long-term follow-up. This insufficient evidence base underscores the need for rigorous, large-scale investigations to identify optimal interventions for anxiety in LRCP patients.
Evaluating the impact of anxiety reduction in LRCP patients
The Patient-Centered Treatment of Anxiety After Low-Risk Chest Pain in the Emergency Room (PACER) study is a randomized clinical trial evaluating three interventions for anxiety following LRCP: enhanced primary care referral (Group 1), online self-guided CBT with peer support (Group 2), and therapist-led telehealth CBT (Group 3).
Participants were recruited from six Indiana University Health emergency departments between April 2021 and July 2024, with 12-month follow-up completed by July 2025. Eligible adults had LRCP, were expected to be discharged within 24 hours, and demonstrated moderate to severe anxiety. Key exclusions included high-risk chest pain, trauma, hospital admission, severe psychiatric conditions, hemodynamic instability, barriers to follow-up, or lack of English proficiency.
Randomization used a permuted block design, stratified by baseline anxiety severity, to assign participants to one of the three groups. Before randomization, all participants received a 15- to 30-minute brief intervention that included psychoeducation about the association between anxiety and LRCP. Group 1 received an enhanced primary care referral, diagnostic results, and educational materials. Group 2 accessed an online CBT program with peer support. Group 3 participated in eight telehealth CBT sessions with a trained therapist. Exposure therapy components were provided to participants in Groups 2 and 3 if panic symptoms were identified.
Assessments were conducted at baseline and at 3, 6, 9, and 12 months. The primary outcome was change in Generalized Anxiety Disorder-7 (GAD-7) scores. Secondary outcomes included measures of depression, somatic symptoms, functional impairment, and tracking of major adverse cardiovascular events (MACE).
CBT-based approaches effectively and safely manage anxiety in LRCP patients
The study enrolled 375 patients, with an average age of 39.9 years, and randomly assigned them to one of the three treatment groups. The participants entered the trial with a substantial burden of psychological symptoms: their average GAD-7 score of 13.1 reflected moderate anxiety, while 58% had depression and 52% had somatization. Panic symptoms were particularly common, with 75% screening positive, while 57% screened positive for PTSD.
Around 80% of participants completed at least one follow-up assessment. Those who did not were more likely to be male, smoke, be unmarried or unpartnered, and screen negative for PTSD.
Over the 12-month follow-up, peer-supported iCBT produced the greatest reduction in anxiety. Participants in group 2 improved by 1.22 points more on the GAD-7 than those receiving enhanced primary care referral, corresponding to an effect size of 0.25 and a statistically significant difference. Therapist-delivered CBT also produced greater improvement than primary care referral, although that difference did not reach statistical significance.
The advantage of peer-supported iCBT was more pronounced among participants who entered the study with severe anxiety. In this group, GAD-7 scores improved by 2.8 points more than with enhanced primary care referral and by 2.2 points more than with therapist-delivered CBT, suggesting that patients with the greatest anxiety burden may have benefited most from the peer-supported approach.
Improvements were not confined to anxiety. Depression, somatization and disability also improved across all three groups, with most of the gains emerging within three months and generally persisting through 12 months. Within-group effects were large for anxiety and moderate for the other outcomes, but there were no significant differences between the groups for depression, somatization, or disability.
The researchers cautioned, however, that these improvements cannot necessarily be attributed entirely to the interventions. Because the study lacked a usual-care group receiving no active intervention, the improvements seen across all three groups could also partly reflect changes over time or regression to the mean.
Engagement appeared to matter. Greater participation was associated with larger reductions in anxiety, particularly with peer-supported iCBT. Compared with participants who did not engage with that intervention, those with moderate and high engagement showed 3.8- and 3.2-point greater improvements in GAD-7 scores, respectively. A similar relationship between engagement and improvement was seen with therapist-delivered CBT.
Patients' own perceptions of their progress also favored the CBT approaches. Participants receiving either form of CBT were more likely to report that their anxiety had improved, with the odds of reaching the different improvement thresholds around two to three times higher than with enhanced primary care referral.
Cardiovascular events remained uncommon during follow-up. Seven major adverse cardiovascular events occurred among six participants, equivalent to a MACE rate of 1.6%, and only one occurred within 30 days of the initial emergency department visit. One participant died during the 12-month study period, but the death was unrelated to cardiac causes.
Participants also responded positively to the CBT programs. Satisfaction was higher in both CBT groups than with enhanced primary care referral, while therapeutic alliance was rated highly and similarly in the peer-supported and therapist-led groups. Meanwhile, the proportions of participants reporting a heart problem, seeing a cardiologist, or discussing anxiety with their primary care physician were similar across the three groups.
Peer-supported online CBT could be a promising anxiety treatment
This study demonstrated that peer-supported iCBT produced a significantly greater reduction in GAD-7 anxiety scores than enhanced primary care referral among ED patients with LRCP and elevated anxiety symptoms. Therapist-administered CBT produced greater numerical improvement than enhanced primary care referral, but the difference on the primary GAD-7 outcome was not statistically significant.
On a separate measure of patients' overall perceived anxiety improvement, both CBT approaches performed better than enhanced primary care referral.
Nevertheless, several limitations warrant consideration, including inconsistent intervention engagement, with about one-third of participants completing no treatment sessions, missing follow-up data for some patients, and a lack of tracking for medication types. Additionally, these results may not be generalizable beyond the single health care system in which the trial was conducted.
Looking ahead, future research should focus on improving intervention adherence and examining these approaches in broader patient populations to confirm their effectiveness.
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