Summary
Background
Several
studies reported a U-shaped association between urinary sodium
excretion and cardiovascular disease events and mortality. Whether these
associations vary between those individuals with and without
hypertension is uncertain. We aimed to explore whether the association
between sodium intake and cardiovascular disease events and all-cause
mortality is modified by hypertension status.
Methods
In
this pooled analysis, we studied 133 118 individuals (63 559 with
hypertension and 69 559 without hypertension), median age of 55 years
(IQR 45–63), from 49 countries in four large prospective studies and
estimated 24-h urinary sodium excretion (as group-level measure of
intake). We related this to the composite outcome of death and major
cardiovascular disease events over a median of 4·2 years (IQR 3·0–5·0)
and blood pressure.
Findings
Increased
sodium intake was associated with greater increases in systolic blood
pressure in individuals with hypertension (2·08 mm Hg change per g
sodium increase) compared with individuals without hypertension (1·22 mm
Hg change per g; pinteraction<0·0001). In those
individuals with hypertension (6835 events), sodium excretion of 7 g/day
or more (7060 [11%] of population with hypertension: hazard ratio [HR]
1·23 [95% CI 1·11–1·37]; p<0·0001) and less than 3 g/day (7006 [11%]
of population with hypertension: 1·34 [1·23–1·47]; p<0·0001) were
both associated with increased risk compared with sodium excretion of
4–5 g/day (reference 25% of the population with hypertension). In those
individuals without hypertension (3021 events), compared with 4–5 g/day
(18 508 [27%] of the population without hypertension), higher sodium
excretion was not associated with risk of the primary composite outcome
(≥7 g/day in 6271 [9%] of the population without hypertension; HR 0·90
[95% CI 0·76–1·08]; p=0·2547), whereas an excretion of less than 3 g/day
was associated with a significantly increased risk (7547 [11%] of the
population without hypertension; HR 1·26 [95% CI 1·10–1·45]; p=0·0009).
Interpretation
Compared
with moderate sodium intake, high sodium intake is associated with an
increased risk of cardiovascular events and death in hypertensive
populations (no association in normotensive population), while the
association of low sodium intake with increased risk of cardiovascular
events and death is observed in those with or without hypertension.
These data suggest that lowering sodium intake is best targeted at
populations with hypertension who consume high sodium diets.
Funding
Full funding sources listed at end of paper (see Acknowledgments).
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