Low-risk chest pain with anxiety: online CBT eased symptoms more than a GP referral

Design

Three-arm randomised comparative effectiveness trial (PACER), 6 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

Internet CBT vs primary care referral: 1.22 points greater improvement (95% CI 0.01 to 2.43)

PACER was a three-arm randomised trial in six US university emergency departments. It enrolled 375 adults, mean age 40, who were discharged after a low-risk chest pain work-up and screened positive for at least moderate anxiety or panic. All received education about anxiety, then either a recommended primary care follow-up, peer-supported internet CBT, or CBT delivered by a therapist by video.

Anxiety scores improved in all three arms over 12 months. Peer-supported internet CBT improved them by 1.22 points more than primary care referral (95% CI 0.01 to 2.43), a small effect, rising to about 2.8 points in people with severe anxiety. Patients in both CBT arms had about three times the odds of reporting that their anxiety had improved. Depression, physical symptoms and disability did not differ between arms.

Patients sent home with a normal troponin and ECG are often told nothing is wrong, and many return. This trial supports naming the anxiety and offering a structured psychological treatment rather than reassurance alone. The between-arm benefit was modest and only just significant, so the strongest case is for people with severe symptoms. Low-cost digital CBT options are available in Indian languages, though they were not tested here.

• Screen for anxiety and panic in patients discharged after a negative chest pain work-up.
• Name the anxiety as a diagnosis rather than closing with reassurance alone.
• Offer CBT, including internet-based options, especially for severe anxiety.
• Arrange follow-up rather than leaving the patient to return to the emergency department.
• Make sure the cardiac work-up was genuinely complete before attributing symptoms to anxiety.

Why it matters

A negative cardiac work-up ends the investigation but not the patient's problem.

Don't overread it

The overall benefit was small and only just significant; the larger effect in severe anxiety is a subgroup finding.

The statistics, in plain English

The 1.22-point difference on a 21-point anxiety scale is small, with an effect size of 0.25, and the lower end of the interval (0.01) is barely above zero. The 2.8-point effect in severe anxiety came from a subgroup, which is less reliable than the main result. Everyone improved, which is partly natural recovery and partly the education all arms received.

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