Salt and cardiovascular disease: insufficient evidence to recommend low sodium intake Martin O’Donnell 1,2,3 *, Andrew Mente 2,3 , Michael H. Alderman 4 , Adrian J.B. Brady 5 , Rafael Diaz 6 , Rajeev Gupta 7 , Patricio Lo ´ pez-Jaramillo 8 , Friedrich C. Luft 9 , Thomas F. Lu ¨ scher 10 , Giuseppe Mancia 11 , Johannes F.E. Mann 12 , David McCarron 13 , Martin McKee 14 , Franz H. Messerli 15 , Lynn L. Moore 16 , Jagat Narula 17 , Suzanne Oparil 18 , Milton Packer 19 , Dorairaj Prabhakaran 20 , Alta Schutte 21 , Karen Sliwa 22 , Jan A. Staessen 23 , Clyde Yancy 24 , and Salim Yusuf 2,3 1 HRB-Clinical Research Facility, NUI Galway, Newcastle Road, Galway, Ireland; 2 Population Health Research Institute, McMaster University, Hamilton, ON, Canada; 3 Hamilton Health Sciences, Hamilton, ON, Canada; 4 Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA; 5 Department of Cardiology, University of Glasgow, Glasgow, UK; 6 Instituto Cardiovascular de Rosario, Estudios Clı ´nicos Latinoame ´rica, Rosario, Argentina; 7 Academic Research Development Unit, Rajasthan University of Health Sciences, Jaipur, Rajasthan, India; 8 Fundacio ´ n Oftalmolo ´ gica de Santander, Instituto Masira, Universidad de Santander, Bucaramanga, Santander, Colombia; 9 D Experimental and Clinical Research Center, Max-Delbru ¨ck Center for Molecular Medicine, Medical Faculty of the Charite ´, Berlin, Germany; 10 Center for Molecular Cardiology, University of Zurich, Switzerland; 11 Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy; 12 KfH Kidney Center, Munich, Germany; 13 Private practice, Portland, OR 97209, USA; 14 London School of Hygiene and Tropical Medicine, London, UK; 15 Department of Cardiology, Inselspital, Bern, Switzerland; 16 Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; 17 The Mount Sinai Medical Centre, New York, NY, USA; 18 Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA; 19 Baylor Hear and Vascular Institute, Baylor University Medical Centre, Dallas, TX, USA; 20 Centre for Chronic Conditions & Injuries, Public Health Foundation of India, Gurugram, India; 21 The George Institute for Global Health, Level 5, 1 King Street, Newtown, New South Wales 2042, Australia; 22 Department of Medicine, University of Cape Town, Cape Town, South Africa; 23 Department of Cardiovascular Diseases, University of Leuven, Leuven, Belgium; and 24 Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 N Saint Claire, Chicago, IL, USA Received 11 October 2019; revised 9 December 2019; editorial decision 29 June 2020; accepted 10 July 2020 Several blood pressure guidelines recommend low sodium intake (<2.3 g/day, 100 mmol, 5.8 g/day of salt) for the entire population, on the premise that reductions in sodium intake, irrespective of the levels, will lower blood pressure, and, in turn, reduce cardiovascular disease occurrence. These guidelines have been developed without effective interventions to achieve sustained low sodium intake in free-living individuals, without a feasible method to estimate sodium intake reliably in individuals, and without high-quality evidence that low sodium intake reduces cardiovascular events (compared with moderate intake). In this review, we examine whether the recommendation for low sodium intake, reached by current guideline panels, is supported by robust evidence. Our review provides a counterpoint to the current recommendation for low sodium intake and suggests that a specific low sodium intake target (e.g. <2.3 g/day) for individuals may be un- feasible, of uncertain effect on other dietary factors and of unproven effectiveness in reducing cardiovascular disease. We contend that current evidence, despite methodological limitations, suggests that most of the world’s population consume a moderate range of dietary sodium (2.3–4.6g/day; 1–2 teaspoons of salt) that is not associated with increased cardiovascular risk, and that the risk of cardiovascular disease increases when sodium intakes exceed 5 g/day. While current evidence has limitations, and there are differences of opinion in in- terpretation of existing evidence, it is reasonable, based upon observational studies, to suggest a population-level mean target of <5 g/day in populations with mean sodium intake of >5 g/day, while awaiting the results of large randomized controlled trials of sodium reduction on incidence of cardiovascular events and mortality. ................................................................................................................................................................................................... Keywords Salt • Diet • Cardiovascular • Prevention * Corresponding author. Tel: þ353-91-494098, Email: martin.odonnell@nuigalway.ie Published on behalf of the European Society of Cardiology. All rights reserved. V C The Author(s) 2020. For permissions, please email: journals.permissions@oup.com. European Heart Journal (2020) 41, 3363–3373 CLINICAL REVIEW doi:10.1093/eurheartj/ehaa586 Prevention Downloaded from https://academic.oup.com/eurheartj/article/41/35/3363/5917753 by guest on 27 October 2022