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VIEWPOINT: STATE-OF-THE-ART PAPER

Placebo and Nocebo in Cardiovascular Health

Implications for Healthcare, Research, and the Doctor-Patient Relationship

University of Iowa Hospitals, Iowa City, Iowa

Manuscript received November 4, 2005; revised manuscript received September 5, 2006, accepted September 7, 2006.

^_* Reprint requests and correspondence: Dr. Brian Olshansky, Cardiac Electrophysiology, University of Iowa Hospitals, 4426a JCP, 200 Hawkins Drive, Iowa City, Iowa 52242. (Email: brian-olshansky{at}uiowa.edu).

Despite treatments proven effective by sound study designs and robust end points, placebos remain integral to elicit effective medical care. The authenticity of the placebo response has been questioned, but placebos likely affect pain, functionality, symptoms, and quality of life. In cardiology, placebos influence disability, syncope, heart failure, atrial fibrillation, angina, and survival. Placebos vary in strength and efficacy. Compliance to placebo affects outcomes. Nocebo responses can explain some adverse clinical outcomes. A doctor may be an unwitting contributor to placebo and nocebo responses. Placebo and nocebo mechanisms, not well understood, are likely multifaceted. Placebo and nocebo use is common in practice. A successful doctor-patient relationship can foster a strong placebo response while mitigating any nocebo response. The beneficial effects of placebo, generally undervalued, hard to identify, often unrecognized, but frequently used, help define our profession. The role of the doctor in healing, above the therapy delivered, is immeasurable but powerful. An effective placebo response will lead to happy and healthy patients. Imagine instead the future of healthcare relegated to a series of guidelines, tests, algorithms, procedures, and drugs without the human touch. Healthcare, rendered by a faceless, uncaring army of protocol aficionados, will miss an opportunity to deliver an effective placebo response. Wise placebo use can benefit patients and strengthen the medical profession.

Abbreviations and Acronyms   AF = atrial fibrillation   CI = confidence interval   ICD = implantable cardioverter-defibrillator   VEGF = vascular endothelial growth factor

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