Effect of Scalable Anxiety Interventions on Emergency Department Utilization and Major Adverse Cardiac Events In Low-Risk Chest Pain Patients

Patients with low-risk chest pain (LRCP) and elevated anxiety frequently return to the emergency department (ED), driving high healthcare utilization. The impact of scalable anxiety interventions on ED recidivism and major adverse cardiac events (MACE) remains unclear. The objective of this study was to compare the effect of three interventions: (1) SBIRT, (2) peer-supported internet-based CBT (iCBT), and (3) therapist-delivered CBT via telehealth, on ED return visits and MACE at 12 months. We hypothesized that all interventions would reduce ED recidivism without increasing MACE, with CBT-based approaches showing greater benefit.

This randomized comparative effectiveness trial (PACER) enrolled 375 adults discharged from seven Indiana EDs after ruling out ACS using a HEART score-based protocol. Participants with moderate to severe anxiety (GAD-7 ≥8) were randomized to one of three arms. ED visits and MACE were tracked for the 12 months pre- and post-enrollment using the statewide Indiana Network for Patient Care and electronic health records. Logistic and negative binomial regression models compared recidivism rates and visit counts across arms.

In the 12 months prior to enrollment, 86.9% of participants had ≥1 ED visit, totaling 1,388 visits. In the 12 months post-enrollment, recidivism declined to 60.3% (SBIRT 58%, iCBT 60%, therapist CBT 63%; p = 0.76), and total visits fell to 1,153, a reduction of 235 (p < 0.0001). Mean visits per participant post-enrollment were similar across arms (SBIRT 3.1, iCBT 3.0, therapist CBT 3.1; p = 0.65). MACE incidence was extremely low (1.6%), with only one event within 30 days and no differences among interventions.

Among ED patients with LRCP and elevated anxiety, all three anxiety interventions were associated with a substantial reduction in ED return visits over 12 months, though rates remained higher than baseline rates of ED recidivism for patients with LRCP. The incidence of MACE was low and comparable across interventions, supporting the safety of integrating behavioral health strategies into acute cardiac care pathways. These findings highlight the potential for scalable anxiety interventions to reduce healthcare utilization and costs without increasing cardiovascular risk.