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Canadian Journal of Cardiology

The Placebo Effect in Cardiology: Understanding and Using It

Published:October 06, 2017DOI:https://doi.org/10.1016/j.cjca.2017.09.017

      Abstract

      The placebo effect is the clinical benefit caused by interaction with a caregiver and health care system in the absence of a biologically active intervention and has been used successfully for millennia. The placebo response results from the interaction of psychosocial mechanisms, human relationships, and preconceptions functioning in specific neuroanatomic locations with known genes and neurotransmitters. It occurs with or without the administration of an inactive substance to deliberately deceive patients. Our purpose is to review the history, benefits, and mechanisms of the placebo effect. The placebo response results from classic conditioning and positive expectations about outcome expressed by the caregiver. The outcomes are usually symptoms such as pain rather than biological outcomes such as death, and the powerful placebo may account for more than half the effect of treatment in many situations. The placebo effect results from activation of opioid, cannabinoid, and dopaminergic pathways involved in reward, expectancy, conditioning, and pain modulation. Eleven specific anatomic features in the brain identified by positron emission tomography and magnetic resonance imaging are involved. Polymorphisms in the structural genes for catecholamine O-methyltransferase and fatty acid amide oxidase significantly influence the placebo response. The placebo effect may be important in symptom suppression in angina, paroxysmal atrial fibrillation, and congestive heart failure. In the absence of deliberate deception, there are no ethical issues and given its potency, the time has come to consider how best to use the placebo in clinical practice.

      Résumé

      Par effet placebo, on entend le bienfait clinique découlant de l’interaction avec un professionnel de la santé et le système de soins de santé en l’absence d’une intervention biologiquement active, phénomène ayant été utilisé avec succès depuis des millénaires. La réponse placebo résulte de l’interaction de mécanismes psychosociaux, de relations humaines et de préconceptions fonctionnant dans des zones neuro-anatomiques précises sur la base de gènes et de neurotransmetteurs connus. Elle survient avec ou sans l’administration d’une substance inactive visant à délibérément tromper le patient. Notre objectif est de revoir l’histoire, les bienfaits et les mécanismes de l’effet placebo. La réponse placebo résulte d’un conditionnement classique et d’une attente positive quant aux résultats exprimés par le fournisseur de soins. Les résultats touchent habituellement des symptômes, comme la douleur, plutôt que des issues biologiques, comme la mort, et la puissance du placebo peut compter pour plus de la moitié de l’effet du traitement dans de nombreuses situations. L’effet placebo résulte de l’activation de voies opioïdes, cannabinoïdes et dopaminergiques impliquées dans la récompense, l’expectative, le conditionnement et la modulation de la douleur. La tomographie par émission de positrons et l’imagerie par résonance magnétique ont permis de déceler la participation de onze composantes anatomiques précises de l’encéphale à ce phénomène. Des polymorphismes observés dans les gènes de structure codant pour la catécholamine-O-méthyltransférase et l’oxydase de l’acide aminé influent de façon importante sur la réponse placebo. L’effet placebo peut jouer un rôle important dans la suppression des symptômes de l’angine, de la fibrillation auriculaire paroxystique et de l’insuffisance cardiaque congestive. En l’absence de tromperie délibérée, il n’y a aucun problème éthique et, en raison de son pouvoir, le temps est venu d’étudier comment tirer le meilleur du placebo dans la pratique clinique.
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