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Yu J, Arnott C, Li Q, Di Tanna GL, Tian M, Huang L, Yin X, Zhang X, Pearson SA, Labarthe DR, Elliott P, Yan LL, Zhou B, Wu Y, Neal B. Secondary Analysis of the Salt Substitute and Stroke Study (SSaSS): Effects of Potassium-Enriched Salt on Cardiac Outcomes. Hypertension 2024; 81:1031-1040. [PMID: 38465623 DOI: 10.1161/hypertensionaha.123.22410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The SSaSS (Salt Substitute and Stroke Study) has shown that use of a potassium-enriched salt lowers the risk of stroke, total cardiovascular events, and premature death. The effects on cause-specific cardiac outcomes are reported here. METHODS SSaSS was an unblinded, cluster-randomised trial assessing the effects of potassium-enriched salt compared with regular salt among 20 995 Chinese adults with established stroke and older age and uncontrolled hypertension. Post hoc efficacy analyses were performed using an intention-to-treat method and a hierarchical Poisson regression model adjusting for clustering to obtain rate ratios and 95% CIs. We assessed acute coronary syndrome, heart failure, arrhythmia, and sudden death. RESULTS Over a mean 4.74 years follow-up, there were 695 acute coronary syndrome events, 454 heart failure events, 230 arrhythmia events, and 1133 sudden deaths recorded. The rates of events were lower in potassium-enriched salt group for all outcomes but CIs were wide for most: acute coronary syndrome (6.32 versus 7.65 events per 1000 person-years; rate ratio, 0.80 [95% CI, 0.65-0.99]); heart failure (9.14 versus 11.32 events per 1000 person-years; rate ratio, 0.88 [95% CI, 0.60-1.28]); arrhythmia (4.43 versus 6.20 events per 1000 person-years; rate ratio, 0.59 [95% CI, 0.35-0.98]); and sudden death (11.01 versus 11.76 events per 1000 person-years; rate ratio, 0.94 [95% CI, 0.82-1.07]; all P>0.05 with adjustment for multiple comparisons). CONCLUSIONS These results suggest that use of potassium-enriched salt is more likely to prevent than cause cardiac disease but the post hoc nature of these analyses precludes definitive conclusions. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02092090.
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Affiliation(s)
- Jie Yu
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- Faculty of Medicine (J.Y., C.A.), University of New South Wales, Sydney, Australia
| | - Clare Arnott
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- Faculty of Medicine (J.Y., C.A.), University of New South Wales, Sydney, Australia
- University of Sydney, Australia (C.A.)
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.A.)
| | - Qiang Li
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
| | - Maoyi Tian
- School of Public Health, Harbin Medical University, Harbin, China (M.T., X.Z.)
| | - Liping Huang
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
| | - Xuejun Yin
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (X.Y.)
| | - Xinyi Zhang
- School of Public Health, Harbin Medical University, Harbin, China (M.T., X.Z.)
| | - Sallie-Anne Pearson
- School of Population Health, Faculty of Medicine and Health (S.-A.P.), University of New South Wales, Sydney, Australia
| | - Darwin R Labarthe
- Northwestern University Feinberg School of Medicine, Chicago, United States (D.R.L.)
| | - Paul Elliott
- School of Public Health (P.E.), Imperial College London, United Kingdom
| | - Lijing L Yan
- The George Institute for Global Health at Peking University Health Science Centre, Beijing, China (L.L.Y., Y.W.)
- Global Health Research Centre, Duke Kunshan University, Kunshan, China (L.L.Y.)
| | - Bo Zhou
- First Hospital of China Medical University, Shenyang, China (B.Z.)
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Centre, Beijing, China (L.L.Y., Y.W.)
- Peking University Clinical Research Institute, Beijing, China (Y.W.)
| | - Bruce Neal
- The George Institute for Global Health (J.Y., C.A., Q.L., G.L.D.T., L.H., X.Y., B.N.), University of New South Wales, Sydney, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China. The Charles Perkins Centre (B.N.)
- Department of Epidemiology and Biostatistics (B.N.), Imperial College London, United Kingdom
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2
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Scarà A, Palamà Z, Robles AG, Dei LL, Borrelli A, Zanin F, Pignalosa L, Romano S, Sciarra L. Non-Pharmacological Treatment of Heart Failure-From Physical Activity to Electrical Therapies: A Literature Review. J Cardiovasc Dev Dis 2024; 11:122. [PMID: 38667740 PMCID: PMC11050051 DOI: 10.3390/jcdd11040122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) represents a significant global health challenge that is still responsible for increasing morbidity and mortality despite advancements in pharmacological treatments. This review investigates the effectiveness of non-pharmacological interventions in the management of HF, examining lifestyle measures, physical activity, and the role of some electrical therapies such as catheter ablation, cardiac resynchronization therapy (CRT), and cardiac contractility modulation (CCM). Structured exercise training is a cornerstone in this field, demonstrating terrific improvements in functional status, quality of life, and mortality risk reduction, particularly in patients with HF with reduced ejection fraction (HFrEF). Catheter ablation for atrial fibrillation, premature ventricular beats, and ventricular tachycardia aids in improving left ventricular function by reducing arrhythmic burden. CRT remains a key intervention for selected HF patients, helping achieve left ventricular reverse remodeling and improving symptoms. Additionally, the emerging therapy of CCM provides a novel opportunity for patients who do not meet CRT criteria or are non-responders. Integrating non-pharmacological interventions such as digital health alongside specific medications is key for optimizing outcomes in HF management. It is imperative to tailor approaches to individual patients in this diverse patient population to maximize benefits. Further research is warranted to improve treatment strategies and enhance patient outcomes in HF management.
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Affiliation(s)
- Antonio Scarà
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Zefferino Palamà
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
| | - Antonio Gianluca Robles
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
- Department of Cardiology, “L. Bonomo” Hospital, 76123 Andria, Italy
| | - Lorenzo-Lupo Dei
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Alessio Borrelli
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Federico Zanin
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Leonardo Pignalosa
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Silvio Romano
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Luigi Sciarra
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
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3
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Mullens W, Damman K, Dhont S, Banerjee D, Bayes-Genis A, Cannata A, Chioncel O, Cikes M, Ezekowitz J, Flammer AJ, Martens P, Mebazaa A, Mentz RJ, Miró Ò, Moura B, Nunez J, Ter Maaten JM, Testani J, van Kimmenade R, Verbrugge FH, Metra M, Rosano GMC, Filippatos G. Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024; 26:730-741. [PMID: 38606657 DOI: 10.1002/ejhf.3244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
Sodium and fluid restriction has traditionally been advocated in patients with heart failure (HF) due to their sodium and water avid state. However, most evidence regarding the altered sodium handling, fluid homeostasis and congestion-related signs and symptoms in patients with HF originates from untreated patient cohorts and physiological investigations. Recent data challenge the beneficial role of dietary sodium and fluid restriction in HF. Consequently, the European Society of Cardiology HF guidelines have gradually downgraded these recommendations over time, now advising for the limitation of salt intake to no more than 5 g/day in patients with HF, while contemplating fluid restriction of 1.5-2 L/day only in selected patients. Therefore, the objective of this clinical consensus statement is to provide advice on fluid and sodium intake in patients with acute and chronic HF, based on contemporary evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sebastiaan Dhont
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Hasselt University, Hasselt, Belgium
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals National Health Service Foundation Trust, London, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
| | - Antonio Cannata
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases, University of Medicine Carol Davila, Bucharest, Romania
| | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine & University Hospital Center Zagreb, Zagreb, Croatia
| | - Justin Ezekowitz
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Andreas J Flammer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V, Genk, Belgium
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Òscar Miró
- Department of Emergency, Hospital Clínic, 'Processes and Pathologies, Emergencies Research Group' IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Brenda Moura
- Hospital das Forças Armadas and Cintesis - Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Julio Nunez
- Cardiology Department and Heart Failure Unit, Hospital Clínico Universitario de Valencia, University of Valencia, INCLIVA, Valencia, Spain
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jeffrey Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Roland van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Marco Metra
- Cardiology, ASST Spedali Civili, and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Cardiology Clinical Academic Group, Molecular and Clinical Research Institute, St Georges University of London, London, UK
- Cardiology, San Raffaele Cassino, Rome, Italy
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4
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Colin-Ramirez E, Arcand J, Saldarriaga C, Ezekowitz JA. The current state of evidence for sodium and fluid restriction in heart failure. Prog Cardiovasc Dis 2024; 82:43-54. [PMID: 38215917 DOI: 10.1016/j.pcad.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
The field of heart failure has evolved in terms of the therapies that are available including pharmaceutical and device therapies. There is now substantial randomized trial data to indicate that dietary sodium restriction does not provide the reduction in clinical events with accepted heterogeneity in the clinical trial results. Dietary sodium restriction should be considered for some but not all patients and with different objectives than clinical outcomes but instead for potential quality of life benefit. In addition, fluid restriction, once the mainstay of clinical practice, has not shown to be of any additional benefit for patients in hospital or in the ambulatory care setting and therefore should be considered to be used cautiously (if at all) in clinical practice. Further developments and clinical trials are needed in this area to better identify patients who may benefit or have harm from these lower cost interventions and future research should focus on large scale, high quality, clinical trials rather than observational data to drive clinical practice.
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Affiliation(s)
| | - Joanne Arcand
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Clara Saldarriaga
- Centro Cardiovascular Colombiano Clinica Santa Maria (Clinica Cardio VID), Antioquia, Colombia
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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5
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Colin-Ramirez E, Sepehrvand N, Rathwell S, Ross H, Escobedo J, Macdonald P, Troughton R, Saldarriaga C, Lanas F, Doughty R, McAlister FA, Ezekowitz JA. Sodium Restriction in Patients With Heart Failure: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Circ Heart Fail 2023; 16:e009879. [PMID: 36373551 DOI: 10.1161/circheartfailure.122.009879] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sodium restriction is a nonpharmacologic treatment suggested by practice guidelines for the management of patients with heart failure (HF). In this study, we synthesized the data from randomized controlled trials (RCTs) evaluating the effects of sodium restriction on clinical outcomes in patients with HF. METHODS In this aggregate data meta-analysis, Cochrane Central, MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase Ovid, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus databases were searched up to April 2, 2022. RCTs were included if they investigated the effects of sodium/salt restriction as compared to no restriction on clinical outcomes in patients with HF. Outcomes of interest included mortality, hospitalization, change in New York Heart Association functional class, and quality of life (QoL). RESULTS Seventeen RCTs were identified (834 and 871 patients in intervention and control groups, respectively). Sodium restriction did not reduce the risk of all-cause death (odds ratio, 0.95 [95% CI, 0.58-1.58]), hospitalization (odds ratio, 0.84 [95% CI, 0.62-1.13]), or the composite of death/hospitalization (odds ratio, 0.88 [95% CI, 0.63-1.23]). The results were similar in different subgroups, except for the numerically lower risk of death with reduced sodium intake reported in RCTs with dietary sodium at the 2000 to 3000 mg/d range as opposed to <2000 mg/d (and in RCTs with versus without fluid restriction as a co-intervention). Among RCTs reporting New York Heart Association change, 2 RCTs (which accounted for two-thirds of the data) showed improvement in New York Heart Association class with sodium restriction. Substantial heterogeneity existed for QoL: 6 RCTs showed improvement of QoL and 4 RCTs showed no improvement of sodium restriction on QoL. CONCLUSIONS In a meta-analysis of RCTs, sodium restriction was not associated with fewer deaths or hospitalizations in patients with HF. Dietary sodium restriction may be associated with improvements in symptoms and QoL.
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Affiliation(s)
| | - Nariman Sepehrvand
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada
| | - Sarah Rathwell
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada
| | - Heather Ross
- Division of Cardiology, Peter Munk Cardiac Center, University of Toronto, Ontario, Canada (H.R.)
| | - Jorge Escobedo
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada
| | - Peter Macdonald
- Heart Failure and Transplant Unit, Cardiology Department, St. Vincent's Hospital, Sydney, Darlinghurst, New South Wales, Australia (P.M.)
| | - Richard Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (R.T.)
| | - Clara Saldarriaga
- Centro Cardiovascular Colombiano Clinica Santa Maria (Clinica Cardio VID), Antioquia, Columbia (C.S.)
| | - Fernando Lanas
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de la Frontera Temuco, Chile (F.L.)
| | | | - Finlay A McAlister
- Canadian VIGOUR Centre, Department of Medicine (N.S., S.R., F.A.M., J.A.E.), University of Alberta, Edmonton, Canada.,Division of General Internal Medicine, Department of Medicine (F.A.M.), University of Alberta, Edmonton, Canada
| | - Justin A Ezekowitz
- Division of Cardiology, Department of Medicine (J.A.E.), University of Alberta, Edmonton, Canada.,Instituto Mexicano del Seguro Social, Mexico City, Mexico (J.A.E.)
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Ezekowitz JA, Colin-Ramirez E, Ross H, Escobedo J, Macdonald P, Troughton R, Saldarriaga C, Alemayehu W, McAlister FA, Arcand J, Atherton J, Doughty R, Gupta M, Howlett J, Jaffer S, Lavoie A, Lund M, Marwick T, McKelvie R, Moe G, Pandey AS, Porepa L, Rajda M, Rheault H, Singh J, Toma M, Virani S, Zieroth S. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial. Lancet 2022; 399:1391-1400. [PMID: 35381194 DOI: 10.1016/s0140-6736(22)00369-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dietary restriction of sodium has been suggested to prevent fluid overload and adverse outcomes for patients with heart failure. We designed the Study of Dietary Intervention under 100 mmol in Heart Failure (SODIUM-HF) to test whether or not a reduction in dietary sodium reduces the incidence of future clinical events. METHODS SODIUM-HF is an international, open-label, randomised, controlled trial that enrolled patients at 26 sites in six countries (Australia, Canada, Chile, Colombia, Mexico, and New Zealand). Eligible patients were aged 18 years or older, with chronic heart failure (New York Heart Association [NYHA] functional class 2-3), and receiving optimally tolerated guideline-directed medical treatment. Patients were randomly assigned (1:1), using a standard number generator and varying block sizes of two, four, or six, stratified by site, to either usual care according to local guidelines or a low sodium diet of less than 100 mmol (ie, <1500 mg/day). The primary outcome was the composite of cardiovascular-related admission to hospital, cardiovascular-related emergency department visit, or all-cause death within 12 months in the intention-to-treat (ITT) population (ie, all randomly assigned patients). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT02012179, and is closed to accrual. FINDINGS Between March 24, 2014, and Dec 9, 2020, 806 patients were randomly assigned to a low sodium diet (n=397) or usual care (n=409). Median age was 67 years (IQR 58-74) and 268 (33%) were women and 538 (66%) were men. Between baseline and 12 months, the median sodium intake decreased from 2286 mg/day (IQR 1653-3005) to 1658 mg/day (1301-2189) in the low sodium group and from 2119 mg/day (1673-2804) to 2073 mg/day (1541-2900) in the usual care group. By 12 months, events comprising the primary outcome had occurred in 60 (15%) of 397 patients in the low sodium diet group and 70 (17%) of 409 in the usual care group (hazard ratio [HR] 0·89 [95% CI 0·63-1·26]; p=0·53). All-cause death occurred in 22 (6%) patients in the low sodium diet group and 17 (4%) in the usual care group (HR 1·38 [0·73-2·60]; p=0·32), cardiovascular-related hospitalisation occurred in 40 (10%) patients in the low sodium diet group and 51 (12%) patients in the usual care group (HR 0·82 [0·54-1·24]; p=0·36), and cardiovascular-related emergency department visits occurred in 17 (4%) patients in the low sodium diet group and 15 (4%) patients in the usual care group (HR 1·21 [0·60-2·41]; p=0·60). No safety events related to the study treatment were reported in either group. INTERPRETATION In ambulatory patients with heart failure, a dietary intervention to reduce sodium intake did not reduce clinical events. FUNDING Canadian Institutes of Health Research and the University Hospital Foundation, Edmonton, Alberta, Canada, and Health Research Council of New Zealand.
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Affiliation(s)
| | | | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | | | - Clara Saldarriaga
- Centro Cardiovascular Colombiano Clinica Santa Maria (Clinica Cardio VID), Antioquia, Columbia
| | | | | | - JoAnne Arcand
- University of Ontario Institute of Technology, Oshawa, ON, Canada
| | - John Atherton
- The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | | | - Milan Gupta
- Brampton Research Associates, Brampton, ON, Canada
| | - Jonathan Howlett
- University of Calgary and Foothills Medical Centre, Calgary, AL, Canada
| | - Shahin Jaffer
- University of British Columbia, Vancouver, BC, Canada
| | | | - Mayanna Lund
- Middlemore Clinical Trials, Auckland, New Zealand
| | - Thomas Marwick
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | | | - Gordon Moe
- St Michael's Hospital, Toronto, ON, Canada
| | | | - Liane Porepa
- Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Miroslaw Rajda
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | | | | | - Sean Virani
- Vancouver General Hospital, Vancouver, BC, Canada
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7
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Stein C, Helal L, Migliavaca CB, Sangalli CN, Colpani V, Raupp da Rosa P, Beck-da-Silva L, Rohde LE, Polanczyk CA, Falavigna M. Are the recommendation of sodium and fluid restriction in heart failure patients changing over the past years? A systematic review and meta-analysis. Clin Nutr ESPEN 2022; 49:129-137. [DOI: 10.1016/j.clnesp.2022.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/18/2022] [Accepted: 03/19/2022] [Indexed: 12/15/2022]
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8
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 706] [Impact Index Per Article: 353.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Abstract
Patients on chronic hemodialysis are counseled to reduce dietary sodium intake to limit their thirst and consequent interdialytic weight gain (IDWG), chronic volume overload and hypertension. Low-sodium dietary trials in hemodialysis are sparse and mostly indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake and IDWG. Additional nutritional restrictions and numerous barriers further complicate dietary adherence. A low-sodium diet may also reduce tissue sodium, which is positively associated with hypertension and left ventricular hypertrophy. A potential alternative or complementary approach to dietary counseling is home delivery of low-sodium meals. Low-sodium meal delivery has demonstrated benefits in patients with hypertension and congestive heart failure but has not been explored or implemented in patients undergoing hemodialysis. The objective of this review is to summarize current strategies to improve volume overload and provide a rationale for low-sodium meal delivery as a novel method to reduce volume-dependent hypertension and tissue sodium accumulation while improving quality of life and other clinical outcomes in patients undergoing hemodialysis.
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Affiliation(s)
- Luis M Perez
- Division of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Denver, CO, USA
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Annabel Biruete
- Department of Nutrition and Dietetics, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
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Ivey-Miranda JB, Almeida-Gutierrez E, Herrera-Saucedo R, Posada-Martinez EL, Chavez-Mendoza A, Mendoza-Zavala GH, Cigarroa-Lopez JA, Magaña-Serrano JA, Rivera-Leaños R, Treviño-Mejia A, Revilla-Matute C, Flores-Umanzor EJ, Espinola-Zavaleta N, Orea-Tejeda A, Garduño-Espinosa J, Saturno-Chiu G, Rao VS, Testani JM, Borrayo-Sanchez G. Sodium restriction in patients with chronic heart failure and reduced ejection fraction: A randomized controlled trial. Cardiol J 2021; 30:411-421. [PMID: 34490604 PMCID: PMC10287066 DOI: 10.5603/cj.a2021.0098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Sodium restriction is recommended for patients with heart failure (HF) despite the lack of solid clinical evidence from randomized controlled trials. Whether or not sodium restrictions provide beneficial cardiac effects is not known. METHODS The present study is a randomized, double-blind, controlled trial of stable HF patients with ejection fraction ≤ 40%. Patients were allocated to sodium restriction (2 g of sodium/day) vs. control (3 g of sodium/day). The primary outcome was change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 20 weeks. Secondary outcomes included quality of life and adverse safety events (HF readmission, blood pressure or electrolyte abnormalities). RESULTS Seventy patients were enrolled. Median baseline sodium consumption was 3268 (2225-4537) mg/day. Adherence to the intervention based on 24-hour urinary sodium was 32%. NT-proBNP and quality of life did not significantly change between groups (p > 0.05 for both). Adverse safety events were not significantly different between the arms (p > 0.6 for all). In the per protocol analysis, patients who achieved a sodium intake < 2500 mg/day at the intervention conclusion showed improvements in NT-proBNP levels (between-group difference: -55%, 95% confidence interval -27 to -73%; p = 0.002) and quality of life (between-group difference: -11 ± 5 points; p = 0.04). Blood pressure decreased in patients with lower sodium intake (between-group difference: -9 ± 5 mmHg; p = 0.05) without significant differences in symptomatic hypotension or other safety events (p > 0.3 for all). CONCLUSIONS Adherence assessed by 24-hour natriuresis and by the nutritionist was poor. The group allocated to sodium restriction did not show improvement in NT-proBNP. However, patients who achieved a sodium intake < 2500 mg/day appeared to have improvements in NT-proBNP and quality of life without any adverse safety signals. CLINICALTRIALS gov Identifier: NCT03351283.
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Affiliation(s)
- Juan B Ivey-Miranda
- Department of Heart Failure, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Eduardo Almeida-Gutierrez
- Department of Research and Direction, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Raul Herrera-Saucedo
- Department of Heart Failure, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Edith L Posada-Martinez
- Department of Echocardiography, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Adolfo Chavez-Mendoza
- Department of Heart Failure, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Genaro H Mendoza-Zavala
- Department of Heart Failure, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Jose A Cigarroa-Lopez
- Department of Heart Failure, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Jose A Magaña-Serrano
- Department of Heart Failure, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Roxana Rivera-Leaños
- Department of Laboratory, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Alberto Treviño-Mejia
- Department of Laboratory, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Cristina Revilla-Matute
- Unidad de Investigación Médica en Enfermedades Metabólicas, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | - Nilda Espinola-Zavaleta
- Department of Nuclear Medicine, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Arturo Orea-Tejeda
- Head of Cardiology Department, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Juan Garduño-Espinosa
- Directorate of Research, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Guillermo Saturno-Chiu
- Department of Research and Direction, Hospital de Cardiologia, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Gabriela Borrayo-Sanchez
- Program "A Todo Corazon", Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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11
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Salt for Patients with Heart Failure and Hyponatremia? Am J Med 2021; 134:e356. [PMID: 33962716 DOI: 10.1016/j.amjmed.2020.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 11/20/2022]
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12
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Patel Y, Joseph J. Sodium Intake and Heart Failure. Int J Mol Sci 2020; 21:ijms21249474. [PMID: 33322108 PMCID: PMC7763082 DOI: 10.3390/ijms21249474] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/05/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022] Open
Abstract
Sodium is an essential mineral and nutrient used in dietary practices across the world and is important to maintain proper blood volume and blood pressure. A high sodium diet is associated with increased expression of β—myosin heavy chain, decreased expression of α/β—myosin heavy chain, increased myocyte enhancer factor 2/nuclear factor of activated T cell transcriptional activity, and increased salt-inducible kinase 1 expression, which leads to alteration in myocardial mechanical performance. A high sodium diet is also associated with alterations in various proteins responsible for calcium homeostasis and myocardial contractility. Excessive sodium intake is associated with the development of a variety of comorbidities including hypertension, chronic kidney disease, stroke, and cardiovascular diseases. While the American College of Cardiology/American Heart Association/Heart Failure Society of America guidelines recommend limiting sodium intake to both prevent and manage heart failure, the evidence behind such recommendations is unclear. Our review article highlights evidence and underlying mechanisms favoring and contradicting limiting sodium intake in heart failure.
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Affiliation(s)
- Yash Patel
- Lifespan Cardiovascular Institute, Warren Alpert Medical School at Brown University, Providence, RI 02914, USA;
| | - Jacob Joseph
- Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02132, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-857-203-6841
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