Elsevier

Journal of Cardiac Failure

Volume 15, Issue 10, December 2009, Pages 864-873
Journal of Cardiac Failure

Clinical Investigation
Long-Term Effects of Dietary Sodium Intake on Cytokines and Neurohormonal Activation in Patients With Recently Compensated Congestive Heart Failure

https://doi.org/10.1016/j.cardfail.2009.06.002Get rights and content

Abstract

Background

A growing body of evidence suggests that the fluid accumulation plays a key role in the pathophysiology of heart failure (HF) and that the inflammatory and neurohormonal activation contribute strongly to the progression of this disorder.

Methods and Results

The study evaluated the long-term effects of 2 different sodium diets on cytokines neurohormones, body hydration and clinical outcome in compensated HF outpatients (New York Heart Association Class II). A total of 173 patients (105 males, mean age 72.5 ± 7) recently hospitalized for worsening advanced HF and discharged in normal hydration and in clinical compensation were randomized in 2 groups (double blind). In Group 1, 86 patients received a moderate restriction in sodium (120 mmol to 2.8 g/day) plus oral furosemide (125 to 250 mg bid); in Group 2, 87 patients: received a low-sodium diet (80 mmol to 1.8 g/day) plus oral furosemide (125 to 250 mg bid). Both groups were followed for 12 months and the treatment was associated with a drink intake of 1000 mL daily. Neurohormonal (brain natriuretic peptide, aldosterone, plasma rennin activity) and cytokines values (tumor necrosis factor-α, interleukin-6) were significantly reduced with a significant increase of the anti-inflammatory cytokine interleukin-10 at 12 months in normal, P < .0001) than low-sodium group. The low-sodium diet showed a significant activation of neurohormones and cytokines and worsening the body hydration, whereas moderate sodium restriction maintained dry weigh and improved outcome in the long term.

Conclusions

Our results appear to suggest a surprising efficacy of a new strategy to improve the chronic diuretic response by increasing Na intake and limiting fluid intake. This counterintuitive approach underlines the need for a better understanding of factors that regulate sodium and water handling in chronic congestive HF. A larger sample of patients and further studies are required to evaluate whether this is due to the high dose of diuretic used or the low-sodium diet.

Section snippets

Patient Population

Between September 2005 and August 2007, 192 patients were consecutively admitted to Biomedical Department of Internal and Specialist Medicine of the University Hospital of Palermo and to department of Cardiology of G.F. Ingrassia Hospital (Palermo) with worsening HF.

Inclusion Criteria

We included into the study only compensated patients who previously were hospitalized (previous 30 days) for recently decompensated congestive HF with the following characteristics: patients had to have, according to the definition

Results

Of the 192 acute HF patients discharged in compensate state and dry profile, 9 patients refused consent to participate to study after discharge, and 10 patients during the 30-day period after discharge did not follow the prescribed limited drink fluid intake (1000 mL) and were also excluded from the study. We obtained 173 (female/male: 68/105) (mean age 72.5 ± 7 years) compensated congestive HF patients (NYHA Class II) and dry weight of different etiologies (84 coronary artery disease, 57

Discussion

To our knowledge, this is the first investigation to assess the effects of 2 different sodium diets in medically treated patients with compensated HF and dry weight on neurohormonal and cytokines activation during 12 months of follow-up. We choose 120 mmol to 2.8 g of Na because epidemiological studies showed that in Europe and Italy it was estimated an assumption of a mean of 3.5 g (150 mmol) Na/day.19, 20 Our data suggest that a moderate sodium restriction with a limited drink fluid intake (1 L)

Conclusion

To date, this counterintuitive approach underlines the need for better understanding of factors that regulate Na and water handling in chronic congestive HF. The observation that the combination of high dose of loop diuretics with moderate sodium restriction may improve clinical outcome and do not determine detrimental effects in renal function suggests that Na depletion has detrimental renal and neurohormonal effects with worse clinical outcome in patients with compensated congestive HF.6, 8,

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    • Are the recommendation of sodium and fluid restriction in heart failure patients changing over the past years? A systematic review and meta-analysis

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      Almost all patients were on optimal pharmacological therapy, including angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), beta-blockers, spironolactone, digitalis, and loop diuretics. Regarding interventions and follow-up, three studies compared fluid restriction versus usual care [9,20,21], with follow-up ranging from 2 to 6 months. The characteristics of fluid restriction included absolute values, such as 1 L/day [9,20], and weight-standardized doses, such as 30 mL/kg/day [21].

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    The authors have no conflicts of interest.

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