#86 Cutting out Sodium in Heart Failure – A Taste of the Evidence
CLINICAL QUESTION
Does sodium restriction improve outcomes in those with systolic heart failure (HF)?
BOTTOM LINE
(Please see correction immediately following).
Factors regulating sodium and water handling in chronic HF remain poorly understood. A meta-analysis of 6 RCTs has important limitations but suggests worsening of outcomes, including an 8 NNH for all-cause mortality. More RCTs are needed, as sodium lowering in HF has not demonstrated clinical benefit in any RCT.
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EVIDENCE
2012 systematic review, six Randomized Controlled Trials (RCTs) with 2,747 systolic HF patients. Compared to 2800mg/day, low sodium diet of 1800mg/day resulted in increased:1
- All-cause mortality, Relative Risk (RR)=1.95 (1.66-2.29), Number Needed to Harm (NNH)=8.
- Death due to HF, RR=2.23 (1.77-2.81), NNH=10.
- Hospital readmissions due to HF, RR=2.10 (1.67-2.64), NNH=5.
- Limitations: All studies authored by one group, adherence uncertain, very high diuretic doses, and inadequate background medical therapy may limit application.
- 302 HF patients, higher sodium (>3000mg/day):2
- Improved event free survival in NYHA class I/II.
- Worsened event free survival in NYHA class III/IV.
- 182 HF patients presenting to emergency with acute decompensation were:
- No more likely to have consumed high sodium foods in the three days prior than those with unrelated symptoms.3
- 123 HF patients who consumed >2800mg sodium/day compared to lesser amounts had:
- Higher incidence of acute decompensated HF.4
- Sodium restriction in HF is based on the theory that increased activity of the reninangiotensin-aldosterone system and other neurohormones results in sodium and water retention.5
- Conversely, others suggest that sodium restriction may in fact trigger compensatory neuroendocrine responses leading to HF exacerbation.6
- Hyponatremia is a powerful predictor of poor long-term prognosis in patients with HF.7-9
- Canadian and US guidelines recommend restricted sodium intake of 2000-3000 mg/day for those with symptomatic HF, considering further restriction in those with moderate to severe HF (consensus of opinion of experts and/or small studies).10,11
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