Effect of Sodium Restriction on Cardiovascular Outcomes in Patients With Hypertension and Heart Failure: A Systematic Review and Meta-Analysis.

Cureus · 2026 · Mixed · Moderate evidence

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MixedModerate evidencePaper 13

Study snapshot

PublicationCureus · 2026

Study typemeta_analysis

Reported directionMixed

Evidence ratingModerate

Abstract

Dietary sodium restriction is a cornerstone of cardiovascular disease management guideline recommendations. However, sodium restriction's impact on hard clinical endpoints in patients with heart failure remains controversial, showing conflicting results compared to the established benefits in essential hypertension. A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational cohort studies evaluating the effect of sodium restriction on all-cause mortality and cardiovascular hospitalization was conducted. Databases were searched through December 2025. Random-effects models were used to pool hazard ratios (HR) with 95% confidence intervals (CI). Heterogeneity was assessed using the I2 statistic, and potential bias was evaluated using the Cochrane Risk of Bias 2 (RoB 2) tool and Newcastle-Ottawa Scale. A total of 20 studies (11 RCTs, nine observational cohorts) involving 306,019 participants were included. In RCTs, the impact of sodium restriction varied significantly by clinical population. While restriction reduced mortality risk in patients with hypertension, it showed a non-significant trend toward harm in patients with established heart failure. In observational studies, low sodium intake was associated with increased mortality risk, supporting a J-shaped relationship. These findings suggest that while sodium restriction is beneficial for hypertension, aggressive restriction in heart failure may not improve outcomes and could be detrimental. This challenges uniform guideline recommendations and highlights the urgent need for personalized dietary management. In observational studies, low sodium intake was associated with increased mortality risk (HR, 1.20 (1.05-1.38)), supporting a J-shaped relationship. Sodium restriction is beneficial for mortality reduction in hypertension but does not improve clinical outcomes in heart failure patients and may be associated with harm in restrictive (<1.5 g/day) regimens. These findings challenge current uniform guideline recommendations for aggressive sodium restriction in heart failure and suggest a need for personalized dietary management.

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AI evidence extraction

Structured fields below were generated from the paper’s abstract and metadata to make the evidence easier to inspect. Automated extraction may be incomplete or incorrect; verify important details against the original paper.

Study typemeta_analysis

Effect directionmixed

PopulationPatients with hypertension and heart failure

Sample size306019

ExposureNot supplied

Evidence strengthModerateConfidence: 74% · Peer reviewed: yes

Main findings

Across 20 studies (11 RCTs, nine observational cohorts), sodium restriction reduced mortality risk in patients with hypertension but showed a non-significant trend toward harm in patients with established heart failure in RCTs. In observational studies, low sodium intake was associated with increased mortality risk (HR 1.20, 95% CI 1.05–1.38), consistent with a J-shaped relationship; aggressive restriction (<1.5 g/day) in heart failure may not improve outcomes and could be detrimental.

Outcomes measured

all-cause mortality
cardiovascular hospitalization

Limitations

Impact varied by clinical population (hypertension vs established heart failure)
Observational findings may reflect a J-shaped relationship and are subject to confounding (as implied by inclusion of cohort studies)
Potential bias assessed with RoB 2 and Newcastle-Ottawa Scale (specific results not provided in abstract)
Heterogeneity assessed with I2 (values not provided in abstract)

View raw extracted JSON

{
  "study_type": "meta_analysis",
  "exposure": {
    "band": null,
    "source": null,
    "frequency_mhz": null,
    "sar_wkg": null,
    "duration": null
  },
  "population": "Patients with hypertension and heart failure",
  "sample_size": 306019,
  "outcomes": [
    "all-cause mortality",
    "cardiovascular hospitalization"
  ],
  "main_findings": "Across 20 studies (11 RCTs, nine observational cohorts), sodium restriction reduced mortality risk in patients with hypertension but showed a non-significant trend toward harm in patients with established heart failure in RCTs. In observational studies, low sodium intake was associated with increased mortality risk (HR 1.20, 95% CI 1.05–1.38), consistent with a J-shaped relationship; aggressive restriction (<1.5 g/day) in heart failure may not improve outcomes and could be detrimental.",
  "effect_direction": "mixed",
  "limitations": [
    "Impact varied by clinical population (hypertension vs established heart failure)",
    "Observational findings may reflect a J-shaped relationship and are subject to confounding (as implied by inclusion of cohort studies)",
    "Potential bias assessed with RoB 2 and Newcastle-Ottawa Scale (specific results not provided in abstract)",
    "Heterogeneity assessed with I2 (values not provided in abstract)"
  ],
  "evidence_strength": "moderate",
  "confidence": 0.74,
  "peer_reviewed_likely": "yes",
  "keywords": [
    "sodium restriction",
    "dietary sodium",
    "hypertension",
    "heart failure",
    "all-cause mortality",
    "cardiovascular hospitalization",
    "randomized controlled trials",
    "observational cohort",
    "J-shaped relationship",
    "meta-analysis"
  ],
  "suggested_hubs": []
}

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AI-extracted fields are generated from the abstract and metadata and may be incomplete or incorrect. This material is for informational purposes and is not medical advice.

Identifiers and source

DOI: 10.7759/cureus.102604
PubMed: 41635382

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