NURS 753 Week 2 Evidence-Based Article Review of the PACER Trial Example

Chest Pain, Normal Heart, Real Anxiety: An Evidence-Based Review of the PACER Trial of Telehealth Cognitive Behavioral Therapy After Low-Risk Emergency Visits

Introduction

Adults arrive at emergency departments with chest pain constantly, and most of these patients leave without a cardiac diagnosis. Many of them have anxiety or panic that is never named, and they return, frightened, with the next episode. For psychiatric nurse practitioners, these patients raise a practical question that the course text by Wheeler (2014) frames well: which psychotherapy, delivered how and by whom, can reach them? This review examines the Patient-Centered Treatment of Anxiety After Low-Risk Chest Pain in the Emergency Room trial, known as PACER, which compared three ways of treating anxiety in these patients (Musey et al., 2026).

Summary of the Article

Purpose and Design

The trial asked whether two telehealth forms of cognitive behavioral therapy were superior to recommended primary care follow-up for adults with low-risk chest pain and anxiety. It was a randomized, three-group comparative effectiveness trial in the emergency departments of six university health systems, enrolling patients from April 2021 to July 2024, with twelve-month follow-up completed in July 2025 (Musey et al., 2026).

Sample and Interventions

Adults discharged after low-risk chest pain were eligible if they had at least moderate anxiety, defined as a GAD-7 score of 8 or more or a positive panic screener. The 375 participants were 70.7% female, 33.3% Black and 7.5% Hispanic, with a mean age of 39.9 years. All three groups received psychoeducation. The groups then received recommended primary care follow-up, peer-supported internet-based CBT or therapist-delivered CBT by telehealth.

Outcomes and Results

The primary outcome was change in the GAD-7 over twelve months, with depression, somatization and disability as secondary outcomes assessed at three, six, nine and twelve months. All three groups improved. Mean GAD-7 scores fell 4.32 points with primary care referral, 5.54 with peer-supported internet CBT and 5.13 with therapist-delivered CBT. Peer-supported internet CBT improved anxiety 1.22 points more than primary care referral (95% CI, 0.01 to 2.43; effect size 0.25), with the largest benefit, 2.8 points, among patients with severe anxiety. Depression, somatization and disability improved within groups without differences between them. The odds of patient-reported global improvement in anxiety were three times higher in both CBT groups than with referral, greater engagement predicted greater improvement, and therapeutic alliance and satisfaction were high in both CBT arms (Musey et al., 2026).

Critique

Strengths

The trial compared realistic options rather than testing therapy against no treatment, which is the question clinicians actually face. Randomization across six health systems strengthens confidence that differences reflect the interventions. A twelve-month follow-up is long for psychotherapy trials and addresses the concern that brief interventions fade. The sample was more diverse than many CBT trials, with a third of participants Black, which improves applicability. The primary outcome, a validated anxiety scale, was measured repeatedly, and the secondary outcomes captured disability and somatic symptoms that matter to patients who arrived with chest pain.

Limitations

The comparison arm was active: every participant received psychoeducation, and referral to primary care led to a 4.32-point improvement, so the trial measures added benefit rather than total benefit. That added benefit was modest. An effect size of 0.25 is small, and the confidence interval nearly reached zero. Therapist-delivered CBT did not show a statistically significant advantage over referral on the primary outcome, despite similar raw improvement, which may reflect limited power for that comparison. Because engagement predicted improvement, patients willing to engage may differ from those who would decline. The abstract does not allow judgment of how many in each arm completed treatment. The strongest finding is not the average difference but who benefited most: patients whose anxiety was severe.

Context

The findings fit broader evidence on internet delivery. A 2025 meta-analysis of 11 randomized trials with 1,272 participants found no significant difference in long-term effectiveness between internet and face-to-face CBT, but adherence was lower for internet CBT, 70.06% compared with 86.68%, and much lower for self-guided than therapist-guided programs (Bakanaitė et al., 2025). PACER's peer support may have served the same purpose as therapist guidance, keeping patients engaged.

Application to Practice

For a psychiatric nurse practitioner who receives referrals from an emergency department, PACER supports offering guided internet CBT as a first step for patients with anxiety after a negative cardiac workup, particularly those with severe anxiety, and reserving therapist-delivered sessions for patients who do not engage online or who prefer live therapy. Consider a composite 42-year-old teacher seen three times in a year for chest pain, with a GAD-7 of 16. A guided online program with weekly peer or clinician check-ins could begin within days, while the nurse practitioner assesses for panic disorder and depression and builds the therapeutic relationship Wheeler (2014) places at the center of psychotherapy. Measuring the GAD-7 at each visit would show whether the program is working. If the score has not fallen by about five points after six to eight weeks, or if panic attacks continue, the nurse practitioner would move to therapist-delivered CBT or add medication, discussing the choice with the patient. The trial's finding that engagement predicted improvement also suggests a practical step: checking at the first follow-up whether the patient has actually logged in, and solving barriers such as time, literacy or a shared device before concluding that the program failed.

Conclusion

The PACER trial shows that peer-supported internet CBT modestly but significantly reduced anxiety over twelve months compared with primary care referral among emergency patients with low-risk chest pain, with the greatest benefit in severe anxiety and higher patient-reported improvement in both CBT arms. Its randomized, multisite design and long follow-up are strengths; its small average effect, active comparison and the nonsignificant result for therapist-delivered CBT are limits. Together with meta-analytic evidence, it supports guided online CBT as an accessible option the psychiatric nurse practitioner can offer early.

References

Bakanaitė, R., Bakanienė, I., & Kanyeredzi, A. (2025). Long-term effectiveness of internet-based versus traditional cognitive behavioral therapy across psychiatric disorders: A systematic review and meta-analysis. Telemedicine and e-Health, 31(11), 1284-1296. https://doi.org/10.1177/15305627251358855

Musey, P. I., Kroenke, K., Connors, J. N., Stump, T. E., Chernyak, Y., Prather, K., Montgomery, C., & Monahan, P. O. (2026). Telehealth treatment of anxiety in patients with low-risk chest pain in the emergency department: The PACER randomized clinical trial. JAMA Internal Medicine. Advance online publication. https://doi.org/10.1001/jamainternmed.2026.4225

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). Springer Publishing.