Effect of a Salt Substitute on Incidence of Hypertension and Hypotension Among Normotensive Adults

Salt versus no salt restriction in heart failure a review

BACKGROUND

For decades standard teaching recommended salt intake (sodium) reduction in patients suffering from heart failure. Neurohumoral activation with subsequent fluid retention provided a solid rationale for this long-standing recommendation. Until recently no large randomized clinical trial of sodium restriction was available, while some observational studies and metanalyses even suggested a worse outcome with strict sodium restriction in patients with heart failure.

METHODS

In this narrative review we aimed to extricate from the literature whether strict sodium restriction is beneficial in patients with heart failure. We searched PubMed indexed articles between 2000 and 2023 for these terms: heart failure, salt, sodium, fluid intake.

RESULTS

Most randomized trials were small and showed a wide heterogeneity of interventions. A single large, randomized clinical trial was stopped early due to futility. Overall, there is no evidence that severe sodium restriction reduces the incidence of mortality and hospitalization in patients with heart failure. Quality of life and functional class may improve slightly with sodium restriction.

CONCLUSION

Morbidity and mortality are not reduced with sodium restriction in patients with heart failure, although some symptomatic improvement may be expected.

The Guidelines for use and promotion of low sodium salt in China

AIM

Both excessive intake of sodium and inadequate intake of potassium are associated with blood pressure elevation and subsequent increase in the risk of cardiovascular disease, which accounts for the largest number of deaths in China and worldwide. Low sodium salt, a mixture of mainly sodium chloride and potassium chloride, has shown its great potential as a promising population strategy for sodium intake reduction through multiple large-scale, multicenter, randomized controlled trials among populations including patients with cardiovascular disease, individuals with and without hypertension, older and younger adults, and men and women in China and other countries. This Guidelines aims to provide expert recommendations for promotion and use of low sodium salt in China, based on the current available scientific evidence regarding the effectiveness, safety, cost-effectiveness, and acceptability of low sodium salts in various population groups and different application scenarios. The suggestions to key stakeholders are also made.

METHODS

A working group, an expert review committee and an advisory committee were established to be responsible for formulating the guidelines' scope and key questions to be addressed, for searching, synthesizing, and evaluating research evidence, proposing and reviewing the recommendations. The consensus on the final recommendations was reached using the GRADE grid method.

RESULTS

The working group summarized current available evidence of salt substitution regarding its effectiveness, safety, cost-effectiveness, acceptability, availability, suitability, etc. The Guidelines provided six recommendations advising different populations how to use low sodium salt, four recommendations on the application of low sodium salts in different scenarios, and five suggestions for key stakeholders to promote salt substitution.

CONCLUSION

The first evidence-based guidelines on promotion and use of low sodium salts covers all key questions in relevance and would play a critical role in prevention and control of hypertension and cardiovascular disease in China and worldwide.