What are the recommendations for a low salt diet in patients with cardiovascular disease?

Low Salt Diet Recommendations for Cardiovascular Disease

For patients with cardiovascular disease, limit sodium chloride (salt) intake to no more than 5-6 grams per day (approximately 2000-2300 mg sodium), with more aggressive restriction to 5 grams per day specifically for those with hypertension or acute decompensated heart failure. 1, 2

Target Salt Intake Levels

General CVD Population

• Aim for less than 5-6 grams of salt per day (equivalent to approximately 2000-2300 mg sodium) for all patients with cardiovascular disease 1, 2
• This translates to reducing salt added to foods during cooking and at the table, as approximately 75-80% of dietary sodium comes from processed foods 3

Hypertension and Heart Failure

• For patients with arterial hypertension or acute decompensated heart failure, restrict salt intake to no more than 6 grams per day 1
• The American Heart Association and European Society of Hypertension recommend this level to achieve meaningful blood pressure reduction and decrease cardiovascular morbidity and mortality 2
• Do not restrict sodium below 2.8 grams of salt per day (120 mmol sodium) in patients with acute decompensated heart failure, as excessive restriction may worsen neurohormonal profiles and increase heart failure hospitalizations 1

Blood Pressure Benefits

The evidence for salt reduction's impact on blood pressure is robust:

• Reducing sodium intake by approximately 1.8 grams per day lowers systolic blood pressure by approximately 4 mmHg and diastolic blood pressure by 2 mmHg in hypertensive patients 2, 3
• Normotensive individuals experience smaller but meaningful reductions of approximately 1/0.6 mmHg 3
• These blood pressure reductions translate to substantial cardiovascular risk reduction, as cardiovascular risk rises steadily with systolic blood pressure values starting from 115 mmHg 3

Practical Implementation Strategy

Dietary Modifications

• Decrease the amount of salt added to foods during cooking and at the table 1
• Choose fresh, frozen, and canned vegetables and fruits without added salt 1
• Compare sodium content between different brands of similar products (such as tomato sauce) and choose lower-sodium options 1
• Limit processed meats that are high in sodium 1
• Use the nutrition facts panel when shopping to identify lower-sodium options 1

Food Industry Role

• Any meaningful strategy to reduce salt intake must rely on food manufacturers reducing the amount added during food processing, as this accounts for the majority of dietary sodium 2, 3

Complementary Dietary Approaches

DASH Diet Pattern

• Follow the Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes vegetables, fruits, and low-fat dairy products while being reduced in saturated fat 2
• This dietary pattern has been shown to have greater blood pressure-lowering effects than salt restriction alone 1

Potassium Intake

• Increase potassium intake to approximately 3000-4700 mg per day through fruits, vegetables, and low-fat dairy products 2
• Good sources include avocados, spinach, nuts, seeds, legumes, and tofu 2

Other Dietary Components

• Reduce saturated and trans-fatty acids to less than 10% of total calories 1
• Limit dietary cholesterol to 300 mg per day 1
• Consider the traditional Mediterranean diet as an excellent model, which is low in saturated fat and associated with optimal cardiovascular outcomes 1

Important Caveats and Special Populations

Avoid Excessive Restriction

• Do not restrict salt below 2.8 grams per day in heart failure patients, as this may activate the renin-angiotensin-aldosterone system and sympathetic nervous system, potentially worsening outcomes 1
• Evidence from cohort studies suggests that sodium intake below 3 grams per day may be associated with increased cardiovascular risk 4, 5

High-Risk Populations

• Black patients and other racial minorities show particularly strong blood pressure responses to dietary salt modification and should be prioritized for salt reduction interventions 2, 6
• Older adults benefit particularly from reductions in coronary heart disease events with salt restriction 6

Chronic Kidney Disease

• For patients with chronic kidney disease and hypertension, salt reduction to a minimum of 3.8 grams per day is indicated 1
• Exercise caution to avoid cumulating restrictive diets (such as low protein plus salt-reduced diets) that increase malnutrition risk 1
• Patients with advanced chronic kidney disease should avoid excessive potassium supplementation and potassium-enriched salt substitutes 2

Liver Cirrhosis

• For patients with liver cirrhosis and ascites, restrict to a no-added salt diet of approximately 5.2 grams per day (90 mmol) 1
• Lower salt intake than recommended for the general population is not advised in cirrhosis with ascites 1

Integration with Medication Management

• In hypertensive patients with controlled blood pressure on medications, salt restriction can facilitate medication step-down or even withdrawal in certain individuals 2
• Salt reduction is as cost-effective as medication treatment for hypertension and should be implemented as a foundational intervention 6

Population-Level Impact

The projected benefits of population-wide salt reduction are substantial:

• Reducing dietary salt by 3 grams per day could prevent 60,000-120,000 new cases of coronary heart disease annually, 32,000-66,000 strokes, and 44,000-92,000 deaths from any cause 6
• The cardiovascular benefits of reduced salt intake are on par with the benefits of population-wide reductions in tobacco use, obesity, and cholesterol levels 6

Monitoring and Adjustment

• Individual blood pressure response to salt reduction varies due to genetic factors and host characteristics such as age 2
• Monitor blood pressure regularly to assess response to dietary sodium restriction 2
• For patients on diuretics and ACE inhibitors, monitor serum potassium and creatinine after 5-7 days of therapy and adjust accordingly 7