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

Abstract

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.

Sodium Intake and Incident Atrial Fibrillation in Individuals With Vascular Disease

“…Low sodium intakes could lead to AF through orthostatic hypotension 33,34 and activation of the renin-angiotensin-aldosterone system, as well as increased adrenaline excretion. 35,36 Besides observational studies that have reported J-or U-shaped associations between sodium intake and cardiovascular outcomes, 8,10,[12][13][14][15][16][17][18] there are also data from interventional studies, 37 including a recent meta-analysis showing an increased risk of in-hospital death in patients with heart failure on sodium-restricted diets in clinical trials 38 and data showing an inverse correlation between country-level sodium intake and life expectancy. 39 Despite this, current guidelines recommend lowering sodium intake to a goal of between less than 1.50 g/d to less than 2.40 g/d.…”

Inadvertent Sodium Administration from Medicines, Intravenous Fluid Therapy, and Diluents in Patients with Heart Failure with Reduced Ejection Fraction Admitted to Cardiac and Non-Cardiac Units in a Tertiary Hospital Network

“…Where ejection fraction was not recorded in the medical record, from the current admission, this data was obtained from the patient's prior admissions. Patients admitted with heart failure with preserved ejection fraction (HFpEF) were excluded due to inadequate evidence for the benefits of restricting sodium intake [13,14]. Additionally, due to research previously undertaken in the intensive care unit (ICU), days in which patients were in ICU were excluded.…”

Salt and Cardiovascular Disease

“…However, contrary to expectation, a recent study in patients with HFpEF revealed that an exaggerated dietary salt restriction could harm patients with HFpEF and is associated with a worse prognosis. 22 Machado et al also found that aggressive salt/water restriction does not provide clinical benefits in patients with HFpEF. 23 A lack of uniformity in limiting the amount of sodium restriction per day, unclear data on the associated use of fluid restriction, and simultaneous usage of diuretics and neurohormonal blockade agents as well as heterogeneity of the HF population studied could provide an explanation for the conflicting evidence in the HFpEF subset.…”

“…However, contrary to expectation, a recent study in patients with HFpEF revealed that an exaggerated dietary salt restriction could harm patients with HFpEF and is associated with a worse prognosis. 22 Machado et al also found that aggressive salt/water restriction does not provide clinical benefits in patients with HFpEF. 23…”