Virtual cognitive-behavioral therapy reduced anxiety among patients after low-risk chest pain.
Chest pain can be frightening even when doctors find no serious heart problem. A new study found that an online form of cognitive behavioral therapy (CBT), helped lower anxiety among people who had low-risk chest pain and were sent home from the emergency department. The benefit was especially noticeable among people who began the study with severe anxiety. Chest pain is one of the most common reasons people visit emergency departments in the United States, with more than 8 million cases each year. Most patients who are checked for a possible heart emergency do not have a heart or lung problem that requires emergency treatment. These cases are often called low-risk chest pain.
Anxiety is common in this group. Research cited in the study found that as many as 55% of patients with low-risk chest pain may have anxiety, while many cases are never diagnosed. Some patients continue to have chest pain and return for medical care even after tests show no heart emergency. Anxiety can also affect daily life and may lead to more healthcare visits. The study, called the PACER trial, looked at three ways to help patients with anxiety after low-risk chest pain. One group received enhanced primary care referrals and educational material. A second group used an online CBT program that included support from peers. The third group took part in eight CBT sessions with a trained therapist through telehealth.
The trial included 375 adults treated at six Indiana University Health emergency departments between April 2021 and July 2024. Participants were expected to leave the hospital within 24 hours and had moderate to severe anxiety. People with high-risk chest pain, serious psychiatric conditions, unstable vital signs, or other conditions that could interfere with the study were not included.
Researchers followed participants for one year and measured anxiety using the Generalized Anxiety Disorder-7, known as the GAD-7. The study group entered the trial with several other mental health concerns. About 58% had depression, 52% had somatization, 75% screened positive for panic symptoms, and 57% screened positive for post-traumatic stress disorder (PTSD). After 12 months, patients using the peer-supported online CBT program had the largest drop in anxiety scores. Their GAD-7 scores improved by 1.22 points more than those of patients who received the enhanced primary care referral. Therapist-led CBT also produced greater improvement than the referral group, but the difference was not large enough to meet the study’s statistical standard.
The online program showed an even larger difference among patients who started with severe anxiety. Their anxiety scores improved by 2.8 points more than those in the primary care referral group and 2.2 points more than those receiving therapist-led CBT. Other measures improved as well. Depression, physical symptoms linked to stress, and problems with daily activities improved across all three groups. Many of these changes appeared within the first three months and continued through the one-year follow-up.
The researchers also found that participation mattered. Patients who took part more often in the peer-supported program generally had larger drops in anxiety scores. Patients who received either type of CBT were also more likely to say their anxiety had improved than those who received the enhanced primary care referral. The study did not find a safety concern involving major heart problems during follow-up. Seven major cardiovascular events occurred among six participants, representing 1.6% of the study group. Only one happened within 30 days of the emergency department visit.
The researchers noted several limits. About one-third of participants did not complete any treatment sessions, some follow-up information was missing, and medication use was not tracked in detail. The study also took place within one health care system, so the results may not apply to every patient or health system. The findings suggest that online CBT with peer support may offer another way to address anxiety after low-risk chest pain, particularly for patients with higher levels of anxiety. More research is needed to see whether the results remain the same in larger and more varied groups of patients.
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Online approach helped patients manage anxiety after chest pain
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