Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial

Ezekowitz, Justin A.; Colin-Ramírez, Eloisa; Ross, Heather J.; Escobedo, Jorge; Macdonald, Peter S.; Troughton, Richard W.; Saldarriaga, Clara; Alemayehu, Wendimagegn; McAlister, Finlay A.; Arcand, JoAnne; Atherton, J.; Doughty, Robert N.; Gupta, Milan; Howlett, Jonathan G.; Jaffer, Shahin; Lavoie, Andrea; Lund, Mayanna; Marwick, Thomas H.; McKelvie, Robert S.; Moe, Gordon W.; Pandey, A. Shekhar; Porepa, Liane; Rajda, Miroslaw; Rheault, Haunnah; Singh, Jitendra; Toma, Mustafa; Virani, Sean; Zieroth, Shelley

doi:10.1016/s0140-6736(22)00369-5

Cited by 88 publications

(83 citation statements)

References 21 publications

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“…If a fluid restriction is really needed, a more liberal intake of 30 to 35 mL/kg of body weight might cause less thirst as was found in the study of Waldréus et al 10 . Although a stringent sodium restriction did not prevent fluid overload and adverse outcomes in patients with HF as was recently found in the SODIUM‐HF study, 20 some restriction of sodium intake and spicy food can be an intervention to prevent symptoms of thirst as some patients themselves suggested in another study 18 …”

Section: Discussionmentioning

confidence: 91%

Thirst in stable heart failure patients; time to reconsider fluid restriction and prescribed diuretics

Wal

Jaarsma

Jenneboer³

et al. 2022

ESC Heart Failure

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Aims One of the bothersome symptoms that heart failure (HF) patients can experience is thirst. There are limited data on the association between thirst and fluid intake and clinical variables. Therefore, the aim of this study was to describe severe thirst in stable HF patients and assess factors related to severe thirst, including actual fluid intake and sodium intake. Methods and resultsThe study had a cross-sectional design. Stable HF patients from two HF clinics in the Netherlands were included and assessed thirst by a visual analogue scale ranging from 0 to 100. They also completed questionnaires on thirst distress, self-care behaviour, and HF symptoms. A 3 day food diary was completed to assess actual fluid intake and sodium intake. Finally, patients collected urine for 24 h. Patients were divided into severe and low thirst based on thirst score and thirst distress. T-tests, Mann-Whitney tests, and χ 2 tests were conducted to assess differences between both groups. Multivariable logistic regression analysis was performed to assess factors associated with severe thirst. A total of 100 patients were included (40% female, mean age 72 ± 12) of which 68 completed the food diary. The mean thirst score was 28 ± 25, and 25% experienced severe thirst. The majority of patients (94%) were prescribed a fluid restriction, 37% had a restriction between 1500 and 2000 mL, and 32% a restriction of 1500 mL. Severe thirst in the total group with 100 patients was associated with a higher dose of loop diuretics [odds ratio (OR) 3.25; 95% confidence interval (CI) 1.01-10.45; P = 0.048] and a higher urine output over 24 h (OR 1.002; 95% CI 1.00-1.003; P = 0.010). In the group of patients who completed the food diary (N = 68), severe thirst was associated with a higher sodium intake (OR 1.002; 95% CI 1.001-1.003; P = 0.003), a higher dose of loop diuretics (OR 22.69;; P = 0.004), and more fatigue (OR 11.2; 95% CI 1.54-82.12; P = 0.017). Conclusions A quarter of all stable HF patients experienced severe thirst. A higher dose of loop diuretics was associated with more thirst; therefore, it might be important to review the dose of loop diuretics critically and try to decrease it in order to relieve severe thirst. Because all patients were prescribed a fluid restriction, a reconsideration of this restriction is also suggested.

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Section: Discussionmentioning

confidence: 91%

Thirst in stable heart failure patients; time to reconsider fluid restriction and prescribed diuretics

Wal

Jaarsma

Jenneboer³

et al. 2022

ESC Heart Failure

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“…Additionally, previous randomised controlled trials have yielded counterintuitive results showing that reduced dietary sodium intake was associated with worse survival and higher readmission rate in patients with HF,6–8 and this association was reinforced in a recent meta-analysis including 3545 patients 19. The most recent randomised controlled trial, the SODIUM-HF trial, which recruited 806 patients with HF and assigned them to either a low sodium diet (<1.5 g/day) or usual care group, also reported that dietary sodium intake restriction did not benefit 1-year clinical outcomes 9. A possible explanation of these results is that low sodium intake might actually result in neurohormonal activation and subsequently aggravate HF, which has been observed in two randomised controlled trials 6 7.…”

Section: Discussionmentioning

confidence: 98%

“…Optimal salt intake in patients with HF has been studied for decades and many published articles have focused on this topic,23 but unfortunately, patients with HFpEF were excluded in most of these studies 10. Even in those not excluding patients with HFpEF, as well as the recently published SODIUM-HF trial, patients with HFpEF were not independently analysed 9 10. As a result, the effect of salt intake restriction in patients with HFpEF is underexplored.…”

Section: Discussionmentioning

confidence: 99%

“…8 The most recent SODIUM-HF trial also reported that reducing dietary sodium intake did not benefit clinical outcomes. 9 Although some observational studies and randomised controlled trials have focused on sodium intake in patients with HF, patients with HFpEF were frequently excluded in these studies. 10 Similar to patients with HF with reduced ejection fraction (HFrEF), patients with HFpEF have HF symptoms and high mortality rate, but patients with HFpEF have a normal or near-normal cardiac function on echocardiography.…”

Section: Introductionmentioning

confidence: 99%

“…Another randomised controlled trial by Parrinello et al even showed a counterintuitive result that diuretic response in patients with compensated HF was improved by increasing sodium intake and limiting fluid intake, and associated with lower readmission and death/readmission rates 8. The most recent SODIUM-HF trial also reported that reducing dietary sodium intake did not benefit clinical outcomes 9…”

Section: Introductionmentioning

confidence: 99%

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Salt restriction and risk of adverse outcomes in heart failure with preserved ejection fraction

Zhen

Huang

et al. 2022

Heart

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BackgroundThe optimal salt restriction in patients with heart failure (HF), especially patients with heart failure with preserved ejection fraction (HFpEF), remains controversial.ObjectiveTo investigate the associations of cooking salt restriction with risks of clinical outcomes in patients with HFpEF.MethodsCox proportional hazards model and subdistribution hazards model were used in this secondary analysis in 1713 participants with HFpEF from the Americas in the TOPCAT trial. Cooking salt score was the sum of self-reported salt added during homemade food preparation. The primary endpoint was a composite of cardiovascular death, HF hospitalisation and aborted cardiac arrest, and secondary outcomes were all-cause death, cardiovascular death and HF hospitalisation.ResultsCompared with patients with cooking salt score 0, patients with cooking salt score >0 had significantly lower risks of the primary endpoint (HR=0.760, 95% CI 0.638 to 0.906, p=0.002) and HF hospitalisation (HR=0.737, 95% CI 0.603 to 0.900, p=0.003), but not all-cause (HR=0.838, 95% CI 0.684 to 1.027, p=0.088) or cardiovascular death (HR=0.782, 95% CI 0.598 to 1.020, p=0.071). Sensitivity analyses using propensity score matching baseline characteristics and in patients who prepared meals mostly at home yielded similar results. Subgroup analysis suggested that the association between overstrict salt restriction and poor outcomes was more predominant in patients aged ≤70 years and of non-white race.ConclusionOverstrict cooking salt intake restriction was associated with worse prognosis in patients with HFpEF, and the association seemed to be more predominant in younger and non-white patients. Clinicians should be prudent when giving salt restriction advice to patients with HFpEF.

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Sodium loading in ambulatory patients with heart failure with reduced ejection fraction: Mechanistic insights into sodium handling

Dauw,

Meekers,

Martens

et al. 2024

European J of Heart Fail

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AimsSodium restriction was not associated with improved outcomes in heart failure patients in recent trials. The skin might act as a sodium buffer, potentially explaining tolerance to fluctuations in sodium intake without volume overload, but this is insufficiently understood. Therefore, we studied the handling of an increased sodium load in patients with heart failure with reduced ejection fraction (HFrEF).Methods and resultsTwenty‐one ambulatory, stable HFrEF patients and 10 healthy controls underwent a 2‐week run‐in phase, followed by a 4‐week period of daily 1.2 g (51 mmol) sodium intake increment. Clinical, echocardiographic, 24‐h urine collection, and bioelectrical impedance data were collected every 2 weeks. Blood volume, skin sodium content, and skin glycosaminoglycan content were assessed before and after sodium loading. Sodium loading did not significantly affect weight, blood pressure, congestion score, N‐terminal pro‐brain natriuretic peptide, echocardiographic indices of congestion, or total body water in HFrEF (all p > 0.09). There was no change in total blood volume (4748 ml vs. 4885 ml; p = 0.327). Natriuresis increased from 150 mmol/24 h to 173 mmol/24 h (p = 0.024), while plasma renin decreased from 286 to 88 μU/L (p = 0.002). There were no significant changes in skin sodium content, total glycosaminoglycan content, or sulfated glycosaminoglycan content (all p > 0.265). Healthy controls had no change in volume status, but a higher increase in natriuresis without any change in renin.ConclusionsSelected HFrEF patients can tolerate sodium loading, with increased renal sodium excretion and decreased neurohormonal activation.

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Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial

Cited by 88 publications

References 21 publications

Thirst in stable heart failure patients; time to reconsider fluid restriction and prescribed diuretics

Thirst in stable heart failure patients; time to reconsider fluid restriction and prescribed diuretics

Salt restriction and risk of adverse outcomes in heart failure with preserved ejection fraction

Sodium loading in ambulatory patients with heart failure with reduced ejection fraction: Mechanistic insights into sodium handling

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