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Low sodium versus normal sodium diets in systolic heart failure: systematic review and meta-analysis
  1. James J DiNicolantonio1,
  2. Pietro Di Pasquale2,
  3. Rod S Taylor3,
  4. Daniel G Hackam4
  1. 1Wegmans Pharmacy, Ithaca, New York, USA
  2. 2Chief Division of Cardiology, “Paolo Borsellino”, G.F. Ingrassia Hospital, Palermo, Italy
  3. 3Peninsula Medical School, University of Exeter, Exeter, UK
  4. 4Division of Clinical Pharmacology, Department of Medicine, and Departments of Clinical Neurological Sciences and Epidemiology & Biostatistics, University of Western Ontario; Stroke Prevention and Atherosclerosis Research Centre (SPARC), Robarts Research Institute, and the Premature Atherosclerosis Program, London Health Sciences Centre, London, Ontario, Canada
  1. Correspondence to Dr James J. DiNicolantonio, 500 South Meadow Street, Ithaca, New York 14850, USA; jjdinicol{at}


Context A low sodium diet has been proposed to reduce the risk of heart failure (HF) hospitalisations and is currently advocated in consensus guidelines, yet some evidence suggests adverse neurohumoral activation for sodium restriction in the HF setting.

Objectives To evaluate the effects of a restricted sodium diet in patients with systolic HF.

Data sources A systematic review and meta-analysis of randomised trials OVID MEDLINE, PubMed, Excerpta Medica (Embase), the Cochrane Controlled Trials Register, Scopus, Web of Science and Google Scholar were searched up to April 2012.

Study selection Two independent reviewers selected studies for inclusion on the basis of a randomised controlled trial design that included adults with systolic HF receiving a restricted salt diet or control diet and reporting mortality (all-cause, sudden death or HF-related) and HF-related hospitalisations.

Data extraction and analysis Descriptive and quantitative information was extracted from included studies. A random-effects model was used to compute pooled risk ratios (RR) for mortality and morbidity outcomes.

Results Six randomised trials comparing low sodium diets (1.8 g/day) with normal sodium diets (2.8 g/d) in 2747 patients with systolic HF were identified. Compared with a normal sodium diet, a low sodium diet significantly increased all cause mortality (RR 1.95, 95% CI 1.66 to 2.29), sudden death (RR 1.72, 95% CI 1.21 to 2.44), death due to HF (RR 2.23, 95% CI 1.77 to 2.81) and HF readmissions (RR 2.10, 95% CI 1.67 to 2.64).

Conclusion Compared with a normal sodium diet, a low sodium diet significantly increases morbidity and mortality in systolic HF.

  • Sodium
  • salt
  • heart failure
  • EBM
  • cardiac function
  • coronary artery disease
  • chest pain clinic
  • heart failure
  • heart failure treatment
  • quality of care and outcomes
  • clinical trials
  • quality of life
  • rehabilitation
  • exercise physiology
  • pharmacology
  • anticoagulation

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  • Editor's note It has been brought to my attention that this meta-analysis draws from a paper in the Journal of Cardiac Failure (Parrinello G, Di Pasquale P, Licata G, et al. Long-term effects of dietary sodium intake on cytokines and neurohormonal activation in patients with recently compensated congestive heart failure. J Card Fail 2009;15:864–73) containing duplicated data. The paper concerned was co-authored by Dr Di Pasquale who is also a co-author of this meta-analysis. He states the data duplication was accidental and points out that the duplicated data were not, in any event, a part of the meta-analysis. I have asked Dr Di Pasquale's institutional director to have the Journal of Cardiac Failure paper reviewed by an independent statistician and if its propriety is confirmed, this notice will be removed.

  • Competing interests RST was lead author on the 2010 Cochrane systematic review of reduced dietary salt and cardiovascular disease.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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