Online CBT helped the anxious patient discharged after low-risk chest pain

Design

Randomised, three-arm comparative effectiveness trial, six emergency departments

Population

375 adults with low-risk chest pain and at least moderate anxiety

Primary outcome

Change in GAD-7 anxiety score over 12 months

Effect

Peer-supported iCBT 1.22 points better than referral (95% CI 0.01–2.43); 2.8 points in severe anxiety

PACER randomised 375 adults discharged from six US emergency departments after low-risk chest pain, all with at least moderate anxiety or panic symptoms, to a recommended primary care follow-up, peer-supported internet CBT or therapist-delivered CBT by telehealth. All three groups received psychoeducation. Mean age was 40 and seven in ten were women.

Anxiety scores (GAD-7) fell in all groups over 12 months: 4.3 points with primary care referral, 5.5 with peer-supported internet CBT and 5.1 with therapist CBT. Internet CBT beat referral by 1.22 points (95% CI 0.01–2.43), and by 2.8 points in those with severe anxiety. Patients in both CBT groups were about three times as likely to report their anxiety had improved. Depression, somatic symptoms and disability did not differ between groups.

The overall difference is modest and only just clears statistical significance. The practical point is the gap it addresses: a negative work-up ends the cardiac question but often leaves the anxiety that brought the patient in, and that patient returns. For physicians who see them in clinic after discharge, screening for anxiety and offering structured CBT, including online, is reasonable.

• Screen patients with repeated low-risk chest pain for anxiety and panic, for example with GAD-7.
• Offer structured CBT, including online programmes, to those with moderate or severe anxiety.
• Explain the negative cardiac result clearly before turning to anxiety, so the patient feels heard.
• Expect the greatest benefit in those with severe anxiety.

Why it matters

Ruling out the heart answers the clinician's question, not the patient's, and this targets what is left.

Don't overread it

The larger benefit in severe anxiety comes from a subgroup and needs confirming.

The statistics, in plain English

An effect size of 0.25 is small. The confidence interval for the main comparison starts at 0.01, just above zero, so the benefit over a primary care referral is real but may be slight for the average patient.

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