Salt Restriction in Heart Failure: Mind the Gap Segment

Core IM

Sodium restriction is commonly recommended to patients with varying stages of heart failure, by both specialists and generalists.  In this episode of Core IM, the team will discuss this scenario and others to offer a better awareness of the evidence base for this practice, and the existence of some literature suggesting potential harm.  Join us for Salt Restrictions in Heart Failure: Mind the Gap Segment.

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Core IM

Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

  • Major cardiology organization guidelines recommend salt restriction to improve outcomes in heart failure.
    • However, the strength of these recommendations have been gradually downgraded in progressive editions.
  • While data for improved clinical endpoints with hypertension is robust, the data for heart failure is limited.
  • Some outpatient randomized controlled trials, while plagued with biases and confounders, have even shown signal towards harm.
    • Several randomized studies have suggested increased mortality and hospital readmissions with salt restriction.
    • Evidence of harm was also found in a large prospective study of 900 patients; Death or HF hospitalization was much higher in the low-salt patients, 42 vs 26%.
  • A sticking point with the outpatient data is they rely on patient reported assessments of their salt intake, which can be very tricky.
    • GOURMET-HF, a trial designed to combat this, and randomized patients to receive low salt pre-prepared meals.
    • While it showed a trend towards decreased re-admissions (11 vs 27%), it was not statistically significant.
  • In the inpatient environment where ideally we can control all the variables, the data does not show signal either.
    • There are a few small trials randomizing inpatients to salt restricted diets or usual care. They did not show clinical improvement with restriction.
  • There is some thought that since salt restriction will decrease sodium delivery to the kidneys, this may lead to upregulation of the neuro-hormonal systems that evidence-based medical therapy seeks to block.
    • The large prospective study noted above did show worse outcomes with salt restriction, however the adverse effects seemed to be limited to those not on ACE/ARB.
    • This suggests that patients who cannot tolerate ACE/ARB may be particularly at risk for adverse outcomes of salt restriction, possibly due to the above proposed mechanism.
  • There is an upcoming trial called SODIUM-HF that hopes to address this issue with better quality data.


Steve Liu, MD - Host

Janine Knudsen, MD  - Host

Armand Gottlieb, MD - Host, CME Questions

Abhinav Nair, MD - Host, Show notes


Mahek Shah, MD

Greg Katz, MD

Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Release Date:  May 20, 2020

Expiration Date: May 20, 2023

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 0.5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.5 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.