Kroenke and colleagues are confusing placebo effects with stress reactions. A placebo classically has a mild blood pressure—lowering effect,1 possibly by reducing the stress associated with blood pressure measurements. On the other hand, a stress reaction to medical testing, such as the one Kroenke and colleagues so vividly describe, may certainly have a pressor effect in normal subjects, but not in patients with severe autonomic failure. Indeed, one of the criteria for this diagnosis is the failure for blood pressure to increase during stress testing (eg, cold pressor test or mental arithmetic).2 No significant blood pressure elevations in response to a placebo have ever been demonstrated in patients with severe autonomic failure.In our report, we focused on the cardiovascular effects of phenylpropanolamine. We concluded that phenylpropanolamine was a potent pressor agent in patients with autonomic failure based on the following: every one of the patients
Biaggioni I, Robertson D. Phenylpropanolamine in Patients With Autonomic Impairment-Reply. JAMA. 1987;258(21):3121–3122. doi:10.1001/jama.1987.03400210063022
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