{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,3]],"date-time":"2026-11-03T03:45:48Z","timestamp":1793677548977,"version":"4.5.1"},"reference-count":74,"publisher":"American Medical Association (AMA)","issue":"11","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Intern Med"],"published-print":{"date-parts":[[2026,11,1]]},"abstract":"<jats:sec>\n                    <jats:title>Importance<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design, Setting, and Participants<\/jats:title>\n                    <jats:p>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\u20137 [GAD-7] score \u22658 or Patient Health Questionnaire [PHQ] panic screener score \u22652) 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main Outcomes and Measures<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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\u2009=\u20090.25) 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions and Relevance<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial Registration<\/jats:title>\n                    <jats:p>\n                      ClinicalTrials.gov Identifier:\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/study\/NCT04811521\">NCT04811521<\/jats:ext-link>\n                    <\/jats:p>\n                  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