Black and Other Ethnic Minorities, As Well as Younger Individuals, Seem To Be at the Most Risk
Although limiting salt consumption is thought to be an important part of treating heart failure, research published in the journal Heart reveals that doing so too severely may potentially make things worse for those who have a common form of the condition.
The findings suggest that the most vulnerable groups are young individuals and those of black and other ethnicities.
Salt restriction is frequently suggested in heart failure guidelines, but the ideal range (from less than 1.5 g to less than 3 g daily) and its impact on patients with heart failure with preserved ejection fraction is unclear because these types of patients are frequently left out of relevant studies.
Heart failure with preserved ejection fraction, which makes up half of all instances of heart failure, happens when the left ventricle, the lower left chamber of the heart, is unable to fill with blood properly (diastolic phase), resulting in less blood being pumped into the body.
The researchers used secondary analysis of data from 1713 TOPCAT trial participants who were 50 years of age or older and had heart failure with preserved ejection fraction in an effort to further investigate the link between salt consumption and heart failure.
A phase III, randomized, double-blind, placebo-controlled study, this trial was designed to find out if the drug spironolactone could effectively treat symptomatic heart failure with preserved ejection fraction.
Participants were asked how much salt they routinely added to the cooking of staples, such as rice, pasta, and potatoes; soup; meat; and vegetables, and this was scored as: 0 points (none); 1 (⅛ tsp); 2 (¼ tsp); and 3 (½+tsp).
Their health was then monitored for an average of 3 years for the primary endpoint, a composite of death from cardiovascular disease or admission to hospital for heart failure plus aborted cardiac arrest. Secondary outcomes of interest were death from any cause and death from cardiovascular disease plus hospital admission for heart failure.
Around half the participants (816) had a cooking salt score of zero: more than half of them were men (56%) and most were of white ethnicity (81%). They weighed significantly more and had lower diastolic blood pressure (70 mm Hg) than those with a cooking salt score above zero (897).
They had also been admitted to hospital more often for heart failure, were more likely to have type 2 diabetes, have poorer kidney function, be taking meds to control their heart failure, and have a reduced left ventricular ejection fraction (lower cardiac output).
Findings on Salt Intake and Health Outcomes
Participants with a cooking salt score above zero were at significantly lower risk of the primary endpoint than those whose score was zero, mainly driven by the fact that they were less likely to be admitted to a hospital for heart failure. But they were no less likely to die from any cause or from cardiovascular disease than those whose cooking salt score was zero.
Younger and Ethnic Minority Patients Show Greater Benefit
Those aged 70 or younger were significantly more likely to benefit from adding salt to their cooking than those older than 70 in terms of the primary endpoint and admission to a hospital for heart failure.
Similarly, those of black and other ethnicities seemed to benefit more from adding salt to their cooking compared with those of white ethnicity, although the numbers were small.
Gender, previous hospital admission for heart failure, and the use of heart failure meds weren’t associated with heightened risks of the measured outcomes and cooking salt score.
This is an observational study, and as such, can’t establish cause. Not all relevant data from the TOPCAT trial were available, while the cooking salt score was self-reported, acknowledge the researchers. And reverse causation, whereby people with poorer health might have been advised to further restrict their salt intake, can’t be ruled out.
Rethinking Salt Restriction in Heart Failure Treatment
Lower sodium intake is usually associated with lower blood pressure and a reduced risk of cardiovascular disease in the general public and in those with high blood pressure. It is thought that it reduces fluid retention and the triggering of the hormones involved in blood pressure regulation.
But restricting salt intake to control heart failure is less straightforward, say the researchers. It may prompt intravascular volume contraction, which could, in turn, reduce congestion and the requirement for water tablets to ease fluid retention.
But their study findings show that the volume of plasma in the blood—an indicator of congestion—-wasn’t significantly associated with cooking salt score, suggesting that low sodium intake didn’t ease fluid retention in people with heart failure with preserved ejection fraction, point out the researchers.
“Overstrict dietary salt intake restriction could harm patients with [heart failure with preserved ejection fraction] and is associated with worse prognosis. Physicians should reconsider giving this advice to patients,” they conclude.
Reference: “Salt restriction and risk of adverse outcomes in heart failure with preserved ejection fraction” by Jiayong Li, Zhe Zhen, Peisen Huang, Yu-Gang Dong, Chen Liu and Weihao Liang, 18 July 2022, Heart.
DOI: 10.1136/heartjnl-2022-321167
The study was funded by the National Natural Science Foundation of China, the Guangdong Natural Science Foundation, and the China Postdoctoral Science Foundation.
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