Sodium Restriction Evidence in HF — EECC MCQ

Correct answer: D — The ESC 2023 HF Guidelines recommend avoiding excessive sodium intake (>5 g/day NaCl) but do NOT recommend severe sodium restriction (<2 g/day NaCl) — the evidence for strict sodium restriction is weak and may cause harm through RAAS activation and reduced palatability leading to malnutrition

Sodium restriction in HF has been debated. The SODIUM-HF trial (2022): 806 HFrEF patients randomised to low-sodium diet (<1500 mg/day) vs usual care → no difference in the composite of death, CV hospitalisation, or ED visits at 12 months. However, symptom improvement (KCCQ) favoured low sodium. The ESC 2023 HF Guidelines take a pragmatic approach: (1) avoid excessive sodium (>5 g/day NaCl — high intake clearly worsens fluid retention); (2) do NOT impose severe restriction (<2-3 g/day) as evidence of benefit is lacking and risks include: RAAS activation (low sodium stimulates renin), reduced food palatability → malnutrition/cachexia (a major prognostic issue in advanced HF), and difficulty with adherence; (3) individualise based on symptoms, congestion, and patient preference. Fluid restriction (1.5-2 L/day) may be more important than sodium restriction in patients with persistent congestion.

Reference: ESC (2023): HF Guidelines; SODIUM-HF Trial