The poll results are based on the clinical vignette of a 65-year-old woman with heart failure with reduced ejection fraction (HFrEF) (EF 35%) with a recent hospitalization for decompensated HF on losartan 50 mg, metoprolol succinate 100 mg and spironolactone 25 mg. As stated in the 2022 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) guideline for HF management, restricting dietary sodium is a common nonpharmacological treatment for patients with HF symptomatic with congestion, but specific recommendations have been based on low-quality evidence without randomized clinical trial data. The SODIUM-HF trial sought to address this gap in knowledge by randomizing patients with chronic HF to usual care or a low sodium diet of less than 1500 mg/day. The study found no significant difference in clinical events of cardiovascular hospitalization, cardiovascular emergency department visit or all-cause mortality at 12 months.

As the novel SODIUM-HF trial data may lead to actionable changes in clinical practice, we created a survey for HF providers to gauge their current practices regarding sodium restrictions, their interpretation of the SODIUM-HF trial, how the trial might impact their clinical practice, and their perception regarding barriers to implementation of changes to dietary reduction of sodium.

The majority of respondents reported that the SODIUM-HF supported a moderate (less than 2g/day) sodium restriction (38 votes, 45.78%) or lenient reduction (less than 3g/day) (37 votes, 44.58%).

Most respondents reported they would recommend moderate restriction of sodium intake (less than 2 g/day) with a total of 75 of 127 votes (59.06%) or lenient reduction of sodium intake (less than 3g/day) at 33 votes (25.98%). A small percentage would recommend strict restriction, less than 1.5g/day (11 votes, 8.66%) and fewer still recommend no reduction in sodium intake (8 votes, 6.3%).

Over 62% of respondents reported SODIUM-HF would not change their practice with one-third reporting they will use patient specific tailored recommendations (34 votes, 36.17%). Of those who reported SODIUM-HF would change their practice, most felt they would be more lenient with sodium restriction (29 votes, 30.85%) versus a few who suggested they would be stricter (6 votes, 6.38%).

Survey results are largely consistent with the prior AHA recommendation for sodium restriction to less than 2300 mg/d for general cardiovascular health promotion.¹ HF specific recommendations regarding sodium restriction are not proscriptive. The current recommendation from the 2022 AHA/ACC/HFSA HF guideline states that for patients with stage C HF avoiding excessive sodium intake is reasonable to reduce congestive symptoms.² This ACC survey suggests that the findings of SODIUM-HF have not changed practice and that most practitioners will continue to recommend lenient to moderate sodium restriction, consistent with current guidelines.³ It will be interesting to reassess whether practices remain consistent after there is more widespread knowledge of the results from SODIUM-HF as sodium restriction may be challenging for many patients.

Figure 1

References

1. Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022;79:e263-e421.
2. Van Horn L, Carson JAS, Appel LJ, et al. Recommended dietary pattern to achieve adherence to the American Heart Association/American College of Cardiology (AHA/ACC) guidelines: a scientific statement from the American Heart Association. Circulation 2016;134:e505-e529.
3. Ezekowitz JA, Colin-Ramirez E, Ross H, et al. 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.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Diet

Keywords: Diet, Sodium-Restricted, Stroke Volume, Losartan, Metoprolol, Spironolactone, American Heart Association, Sodium, Dietary, Heart Failure, Hospitalization, Surveys and Questionnaires, Emergency Service, Hospital, Perception, Health Promotion, Sodium

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