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Does Salt Intake Really Affect Outcomes in Heart Failure Patients? | Latest news for doctors, nurses and pharmacists

A small, single-center study suggested that increasing sodium intake does not affect weight or kidney function in patients hospitalized with acute heart failure (HF) on aggressive diuretic therapy.

“We found no difference in the primary endpoint or safety despite a median dose of 13 g sodium chloride in the treatment group,” presented study author Dr. Robert Montgomery. from the Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic, Cleveland, Ohio. , USA, at HFSA 2022.

In the double-blind OSPREY-AHF* trial, 65 adults (mean age 70 years, 37% female) hospitalized (non-ICU) with acute HF were randomized 1:1 to receive sodium chloride per orally (2 g) or placebo TID during intravenous diuretic therapy in addition to the low sodium diet provided in the hospital. Patients had to have NT-proBNP levels 1000 ng/L and be treated with furosemide
10 mg/hour to include. Patients with acute coronary syndrome, eGFR 2malabsorptive gastrointestinal disorders or hypernatremia (serum sodium > 145 or

Forty-nine percent of patients had CI with preserved ejection fraction. Mean eGFR at baseline was 39 mL/min/1.73 m2. The most common comorbidities were hypertension and atrial fibrillation (71 and 68%, respectively). Patients had had an average of two hospitalizations for HF in the previous year. The most commonly used drugs were beta-blockers, mineralocorticoid receptor antagonists, and hydralazine and/or isosorbide dinitrate (72, 52, and 52%, respectively). Baseline characteristics were generally well balanced between the groups, although patients assigned to the sodium chloride group had higher serum creatinine levels compared to placebo (2.0 vs 1.6 mEq/L).

At 96 hours, the change in creatinine levels and weight did not differ significantly between patients on sodium chloride and on placebo (p=0.33). This lack of difference applied to both change in creatinine levels (0.04 [sodium chloride] against 0.15 [placebo] mg/dl; p=0.30) and change in weight (–4.0 vs –4.6 kg; p=0.57). [HFSA 2022, session: Late Breaking Clinical Trials 1]

Serum sodium levels decreased more in the placebo vs sodium chloride group (–2.6 vs –0.03 mEq/L; p

Other secondary outcomes such as changes in Distress-Thirst-HF score (–1.2 [sodium chloride] against 0.1 [placebo]; p = 0.39), serum chloride level (–1.0 vs –3.0 mEq/L; p = 0.19) and eGFR level (–2.3 vs –3.3 mL/min/1 .73m2; p = 0.18) did not differ between groups. The recorded total urinary flow rate was also comparable between the groups (10,000 vs 9,400 ml; p = 0.61).

Time to discharge from hospital (from enrollment) was similar between patients in the sodium chloride and placebo groups (8 vs 7 days). Three and five patients, respectively, were admitted to intensive care during their hospitalization. Two and one patients, respectively, required renal replacement therapy within 90 days of enrollment. Seven patients from each group were readmitted to hospital within 30 days. There have been four and three deaths respectively in 90 days.

There was no significant difference between groups in terms of serious adverse events, although the trial was underpowered to detect differences between groups. The apparent lack of harm underscores the need for larger clinical trials to assess the effect of sodium chloride in this patient population, Montgomery said.

A necessary change of mentality?

“Since the 1940s, we’ve been taught that salt is the main reason people become fluid-congested, leading to the idea that we need to keep people low on salt while they’re in the hospital with fluid overload,” said lead author Dr. Wilson Tang of the Heart, Vascular & Thoracic Institute at the Cleveland Clinic, Cleveland, Ohio, USA.

However, low sodium intake is associated with complications such as decreased nutritional quality or caloric intake, decreased diuretic response, and increased activation of the renin-angiotensin-aldosterone system and renal sodium craving, noted Montgomery.

“There have even been reports of potential benefits of salt infusion to facilitate urination with high-dose diuretic drugs in patients with congestive heart failure. However, our study did not show such benefits with increased oral salt supplementation and gave us an indication that maintaining a low-salt diet during aggressive diuretic therapy may not be as effective as we thought,” Tang added.

“We believe that the null result of this study calls into question the common practice of sodium chloride restriction in acute HF,” Montogomery pointed out.

“[Nonetheless,] our results do not imply that patients with HF should start eating more salt, as we only studied the role of oral salt supplementation in people receiving high-dose diuretics while hospitalized” , Tang said. “Patients with IC should always be aware that excessive salt intake can cause fluid congestion,” he concluded.