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#368 Sodium Restriction in Heart Failure: Beneficial or pouring salt in the wound?


CLINICAL QUESTION
QUESTION CLINIQUE
 Does sodium restriction improve outcomes in patients with chronic heart failure?

BOTTOM LINE
RÉSULTAT FINAL
 In patients with chronic heart failure, restricting dietary sodium to <2 grams/day does not reduce death or hospitalization compared with 2-3 grams/day.


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EVIDENCE
DONNÉES PROBANTES
  • Five systematic reviews assessed dietary sodium restriction in patients with heart failure (5-17 randomized controlled trials [RCTs], 479-1683 participants).1-4
    • Focusing on the most comprehensive systematic review:1
      • Sodium restriction <2 grams/day in 11 RCTs and 2-3 grams/day in 6 RCTs; usual care ranged from 2-5 grams/day (when reported) with duration 1 week to 1 year; 13 RCTs in outpatients, 4 in inpatients.
      • No significant differences in death (all-cause or cardiovascular) or hospitalizations (all-cause or cardiovascular).
    • Sodium restriction increased mortality and/or hospitalization in three reviews:2-4
      • Driven by 2-4 RCTs with several issues from same authors: Including duplicate reporting, inadequate background medications, very high furosemide doses (250-1000 mg/day) and tight fluid restriction (<1 L/day) not representative of current practice.5,6
  • Focusing on the largest (806 patients) unblinded RCT, SODIUM-HF:7 Patients with chronic heart failure with any ejection fraction (>99% New York Heart Association class 2-3) and baseline dietary sodium intake ~2.2 grams/day randomized to dietician support targeting sodium <1.5 grams/day (achieved ~1.7 grams/day) versus usual care (achieved ~2.1 grams/day). At 1 year:
    • Death or cardiovascular emergency department visit or hospitalization: 15% versus 17% (usual care), not statistically different.
  • Sodium restriction does not consistently improve heart failure symptoms or quality of life.1,4,7
CONTEXT
CONTEXTE
  • Sodium restriction theory: Renin-angiotensin-aldosterone system activation in heart failure results in sodium and water retention. Yet, excess sodium restriction could also exacerbate activation.5
  • A previous Tools for Practice initially suggested sodium restriction worsened outcomes, but cautioned about flawed RCTs and was later updated after the original supporting systematic review was retracted.5
  • The average Canadian consumes ~2.8 grams/day of sodium.8
  • Canadian guidelines recommend restricting sodium intake to 2-3 grams/day, whereas American and European guidelines recommend avoiding “excess” sodium intake without defining specific amounts.9
  • In patients hospitalized for acute heart failure, restricting sodium (<800 mg/day) and fluids (<800 mL/day) increased thirst without reducing signs or symptoms of congestion.10

Pierre-Paul Tellier June 27, 2024

Very interesting and useful

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Author(s)
Auteur(s)
  • Ricky D. Turgeon BSc(Pharm) ACPR PharmD
  • James McCormack BSc(Pharm) PharmD
  • Jen Potter MD CCFP

1. Colin-Ramirez E, Sepehrvand N, Rathwell S, et al. Circulation Heart Fail. 2023; 16:e009879.

2. Stein C, Helal L, Migliavaca CB, et al. Clinical Nutrition ESPEN. 2022; 49:129-37.

3. Urban S, Fulek M, Blaziak M, et al. Clin Res Cardiol. 2023; doi:10.1007/s00392-023-02256-7.

4. Zhu C, Cheng M, Su Y, et al. J Cardiovasc Nurs. 2022; 37:570-80.

5. Korownyk C, McCormack J. Tools for Practice #86. Available at: https://cfpclearn.ca/tfp86/. Accessed 2024 Jan 5.

6. Francis GS. J Card Fail. 2013; 19:523.

7. Ezekowitz JA, Colin-Ramirez E, Ross H, et al. Lancet. 2023; 399:1391-400.

8. Health Canada. Sodium intake of Canadians in 2017. Ottawa, ON: Health Canada; 2018. Available from: https://www.canada.ca/content/dam/hc-sc/documents/services/publications/food-nutrition/sodium-intake-canadians-2017/2017-sodium-intakes-report-eng.pdf Accessed 2024 Jan 4.

9. MacDonald BJ, Virani SA, Zieroth S, et al. Can J Cardiol Open. 2023; 5:629-40.

10. Badin G, Rabelo ER, Clausell N, et al. JAMA Intern Med. 2013; 173:1058-64.

Authors do not have any conflicts of interest to declare.