Transcript Nessun titolo diapositiva - ASIAM

Il consumo di sodio e potassio e ipertensione
Alberto Morganti
U.O. Medicina Generale e Centro Ipertensione Arteriosa
Ospedale San Giuseppe, Università di Milano
Congresso Nazionale ASIAM
Riccione, 16-18 Maggio 2014
1910 Mo
Progressi nel Trattamento dell’Ipertensione Arteriosa
1940
• Dieta iposodica (Kemper)
• Simpaticectomia lombodorsale
1970
• Bloccanti recettori alfa-adrenergici
• ACE inibitori
1950
• Simpaticolitici (Reserpina,
Guanetidina)
• Vasodilatatori (Idralazina)
• Diuretici tiazidici
1980
• Calcioantagonisti
1960
• Bloccanti recettori beta-adrenergici
• Antialdosteronici (Spironolattoni)
2077 Mo
1990
• Bloccanti recettori angiotensina II
(Sartani)
2000
• Inibitori diretti della renina
Salt intake and the rise in blood pressure with age
Increase in SBP with age (mmHg/y)
1.4
INTERSALT Study
Data from 52 centers
r = 0.566
p < 0.001
1.2
1.0
0.8
0.6
0.4
0.2
0.0
-0.2
0
3
6
9
12
15
Urinary sodium excretion (gr salt/day)
2929 Mo
INTERSALT Cooperative Research Group, BMJ 1988; 297: 319-328
Relationship between salt intake and death from stroke
Deaths from stroke (per 106 per year)
2210
1810
Data from 12 EU countries
r = 0.832
p < 0.001
1480
1210
990
810
670
550
7.5
8.0
8.5
9.0
9.5
10.0
10.5
Urinary sodium excretion (gr salt/day)
2930 Mo
Perry and Beevers, J Human Hypertens 1992; 6: 23-25
Mechanisms whereby high sodium intake may cause CVD
Increase in BP
LVH, ventricular fibrosis
Diastolic dysfunction
Endothelial dysfunction
Increased vascular oxidative stress
Increased mitogenic responses
Increased urinary calcium excretion
Nephrocalcinosis
Proteinuria
2936 Mo
Meta-analysis of prospective studies comparing the effects of
higher vs lower salt intake on incident CV events and stroke
Studies
Sample
size
Events
Follow-up
(years)
Sodium
difference
(mmol/day)
RR
P
40-150
1.17
0.02
84-150
1.23
0.01
CV diseases
14
104.933
5.161
3.5-19
Stroke
14
154.282
5.343
3.5-19
5 gr/day reduction in salt intake can avert a quarter million deaths from stroke and three million
deaths from CV disease each year throughout the world
2909 Mo
Strazzullo P et al., BMJ 2009; 339: b4547
Hazard Ratio for CVD by mean daily sodium excretion
in prehypertensive individuals
20
10
n = 2275, F.U. 10-15 yrs
193 CV events
Mean Na+ excretion 3630 mg/day
Hazard Ratio
5
2
1
0.5
0.2
1000
2000
3000
4000
5000
6000
7000
8000
9000
Na excretion (mg/day)
Data from TOPH I and TOPH II Studies
2922 Mo
Cook NR et al., Circulation 2014; 129: 981-989
Deaths from stomach cancer (per 105 per year)
Relationship between salt intake and death from stomach cancer
Data from 21 countries
r = 0.702
p < 0.001
180
160
140
120
100
80
60
40
20
0
6
7
8
9
10
11
12
13
14
Urinary sodium excretion (gr salt/day)
2931 Mo
Joossens JV et al., J Epidemiol 1996; 25: 494-504
Meta-analysis of prospective studies comparing the effects of
higher vs lower potassium intake on incident stroke, CAD and CVD
Studies
Sample
size
Events
K+ difference
(mmol/day)
RR
Men
Women
P
0.79
0.81
0.70
0.01
0.92
-
-
n.s.
0.85
0.91
0.65
0.3
Stroke
11
233.606
7.066
10-68
CAD
6
81.612
3.058
19-68
CVD
4
2910 Mo
62.453
2.497
22-50
D’Elia L et al., JACC 2011; 57: 1210-1219
Relationship between moderate daily urinary sodium reduction and
changes in blood pressure in normotensive and hypertensive subjects
4
Change in SBP (mmHg)
2
0
-2
Normotensives
(n = 13 studies)
-4
-6
Hypertensives
(n = 16 studies)
-8
-10
-12
30
2
50
3
70
4
90
5
110
6
7
130 (mmol/24h)
(g/day of salt)
Reduction in urinary sodium
2928 Mo
He FJ et al., J Human Hypertens 2002; 16: 761-770
Effects of dietary sodium reduction on blood pressure
in subjects with resistant hypertension
Weight
(kg)
Sodium
excretion
(mmol/day)
Office
SBP
(mmHg)
Office
DBP
(mmHg)
ABPM
SBP
(mmHg)
ABPM
DBP
(mmHg)
BNP
(pg/ml)
High salt
91.5
252
146
84
150
82
38
Low salt
90.1
46
123
75
130
73
14
P
0.05
0.001
0.01
0.01
0.01
0.01
0.01
Data from 12 pts randomized to cross-over evaluation of low (50 mmol) and high (250 mmol)
sodium diets for 7 days separated by 2 weeks w.o. period
2914 Mo
Pimenta E et al., Hypertension 2009; 54: 475-481
Effect on SBP and DBP of reduced sodium intake
and the DASH diet
Systolic Blood Pressure
mmHg
85
mmHg
135
Control
diet
130
Diastolic Blood Pressure
Control
diet
-2.1
-2.9
-5.9
DASH
diet
80
-1.3
2912 Mo
DASH
diet
-2.5
-0.6
-2.2
125
mmol/day
-2.4
-4.6
-5.0
120
-1.1
-1.0
-1.0
-1.7
75
Higher
Intermediate
Sodium Intake
Lower
144/141
107/106
67/64
Higher
Intermediate
Sodium Intake
Lower
Sacks FM et al., NEJM 2001; 344: 3-10
Effect on SBP of reduced dietary sodium intake
during the control diet and DASH diet in subgroups of subjects
Change
in SBP
(mmHg)
Control diet
2
0
-2
*
‡
-4
‡
-6
-8
†
*
*
‡
‡
*
‡
‡
-10
High to
sodium
High to
sodium
-12
DASH diet
2
Change
in SBP
(mmHg)
intermediate
intake
low
intake
0
-2
†
-4
*
*
*
‡
‡
-6
-8
2911 Mo
Blacks
with HT
Others
with HT
* P < 0.05; † P < 0.01; ‡ P < 0.001
Blacks
without
HT
Others
without
HT
Men
Women
Sacks FM et al., NEJM 2001; 344: 3-10
Effects of graded reduction in sodium intake in nonhypertensive and
hypertensive patients older than 45 years of age
Nonhypertensive
Hypertensive
mmHg
145
mmHg
130 Control
diet
125
Control
diet
-2.9
140
-6.7
135
DASH
diet
2913 Mo
-7.5
DASH
diet
-1.6
-1.2
115
-6.0
-8.0
-4.1
-5.0
120
--2.1
-6.7
-2.5
-1.6
130
-5.1
125
Higher
Intermediate
Sodium Intake
Lower
Higher
Intermediate
Sodium Intake
Lower
Bray GA et al., Am J Cardiol 2004; 94: 222-227
Long-term effects of salt restriction in newborn babies
Double blind
Usual salt
Differences in SBP (mmHg)
1
Usual salt
0
-1
P < 0.01
-2
P < 0.02
Reduced salt
-3
-4
5
wks
9
wks
13
wks
17
wks
21
wks
25
wks
(n = 476)
15
yrs
(n = 167)
Age
2932 Mo
Hofman A et al., JAMA 1983; 250: 370-373
Meta-analysis of moderate salt intake reduction
in normotensive and hypertensive subjects
Normotensive
Hypertensive
3
3
Reduction in salt intake (gr/day)
2.0
2.3
Fall in SBP (mmHg)
-1.1
-4.1
Fall in DBP (mmHg)
-0.8
-3.7
Reduction in overall mortality (all causes)
10%
4%
Reduction in CVD events
29%
16%
Trials
Reduction in CVD mortality
2908 Mo
31%
He FJ and MacGregor GA, Lancet 2011; 378: 380-382
Projected estimates of comparative effect of various population
interventions on annual reductions in cardiovascular events
Intervention
Incidence of
CHD
Total
MI
Incidence of
stroke
Death from
any cause
Reduction in absolute number of events
Salt reduction
1 g/day
Low estimate
22.000
20.000
13.000
17.000
3 g/day
Low estimate
66.000
58.000
37.000
51.000
Smoking cessation
41.000
92.000
32.000
84.000
Weight loss
59.000
61.000
5.600
36.000
2917 Mo
Bobbins-Domingo K et al., NEJM 2010; 362: 590-599
Projected estimates of the cost and effectiveness of salt reduction and
hypertension treatment annually and cumulatively, 2010-2019 in US
Intervention
Reduction in
health care costs
(billions of dollars)
Cost saved per dollar
spent on intervention
(dollars)
Reduction in dietary salt
1 g/day
Low estimate
3 g/day
Low estimate
4.1
15.4
12.1
45.2
Hypertension treatment
14.2
Gradual reduction in dietary salt, 2010-2019
1 g/day
Low estimate
3 g/day
Low estimate
18.9
7.0
56.9
21.2
2921 Mo
Bobbins-Domingo K et al., NEJM 2010; 362: 590-599
Potential impact on CVD & estimated cost
Salt reduction vs tobacco control
15% reduction in
salt intake
20% reduction in
smoking prevalence
N° of CVD deaths
averetd (x106)
10
8
6
4
2
Annual cost per
person (US$)
0
0.30
0.20
0.10
0.00
2933 Mo
Asaria P et al., Lancet 2007; 370: 2044-2053
Daily sodium and potassium excretion in hypertensive patients
Data from the MINISAL-SIIA Study Program
Sodium excretion (mmol/day)
200
10.1 gr salt
90% > WHO
160
Potassium excretion (mmol/day)
100
8.1 gr salt
81% > WHO
80
120
60
80
40
40
20
0
Men
n = 631
Women
n = 601
0
2.5 gr
92% < WHO
Men
n = 631
2.1 gr
95% < WHO
Women
n = 601
Data from 1232 hypertensive patients (age range 19-89 yrs) from 47 centers
Recommended sodium intake 85 mmol = 2 gr/day, and 5 gr of salt, potassium intake 100 mmol = 3.9 gr/day
2920 Mo
Galletti F et al., J Hypertens 2014; 32: 48-56
Average daily salt intake in male and female Americans
Males
Females
12
Salt intake (g/day)
10
8
6
5.8
(2300 mg sodium)
4
3.8
(1500 mg sodium)
2
0
2-4
4-8
9-13
14-18
19-30
31-50
51-70
≥ 71
Age (yr)
2919 Mo
Appel LJ and Anderson LAM, NEJM 2010; 362: 650-652
Mean sodium / potassium excretion ratio in hypertensive patients
Data from the MINISAL-SIIA Study Program
4
1.7% < 0.85
1.5% < 0.85
2.99
3
2.71
2
1
0
Men
n = 631
Women
n = 601
Data from 1232 hypertensive patients from 47 centers
Recommended sodium / potassium ratio: 0.85
2925 Mo
Galletti F et al., J Hypertens 2014; 32: 48-56
Sex specific daily sodium and potassium excretion by quartiles of
age and BMI - Data from the MINISAL-SIIA Study Program
Age
BMI
Sodium
(mmol)
Potassium
(mmol)
Sodium
(mmol)
Potassium
(mmol)
Men
I
II
III
IV
P<
185
174
171
156
0.01
62
66
66
58
n.s.
165
163
173
185
0.01
62
61
65
64
n.s.
Women
I
II
III
IV
P<
145
143
127
132
0.01
59
58
55
50
0.01
124
126
148
152
0.01
54
53
57
60
0.02
2924 Mo
Galletti F et al., J Hypertens 2014; 32: 48-56
Strategy for reducing salt
Salt intake
Source
g/day
Reduction
needed
Table / Cooking (15%)
1.4 g
40% reduction
0.9 g
Natural (5%)
0.6 g
No reduction
0.6 g
Food industry (80%)
7.5 g
40% reduction
4.5 g
Total 9.5 g
2934 Mo
Target intake
g/day
Total 6.0 g
He FJ, MacGregor G, J Human Hypertens 2009; 23: 363-384
Effects of doctor’s advice about salt reduction in Italy
Data from the MINISAL-SIIA Study Program
Sodium excretion
(mmol/day)
Patients receiving advice
53%
159.7
Patients not receiving advice
47%
156.1
Patients adhering to advice
31%
149.4
* p < 0.001
Patients not adhering to advice
69%
171.2
n = 1232 hypertensive patients from 47 centers
2926 Mo
Galletti F et al., J Hypertens 2014; 32: 48-56
The commercial importance of salt in processed food
Salt
Producers
Food industry
Highly salted processed food
(80% of total intake)
2935 Mo
Salt addiction
Thirst
Meat products - Salt added
Demand for
salty food
Soft drinks
Mineral water
Increase in weight
by water binding
Profit
Profit
Profit
He FJ, MacGregor G, J Human Hypertens 2009; 23: 363-384
Raccomandazioni della Società Internazionale dell’Ipertensione (ISH)
per ridurre il consumo di sale dietetico
Sviluppare programmi di informazioni sui rischi della dieta ricca di sale
Utilizzare i media per raggiungere il grande pubblico
Ridurre il contenuto di sale in tutti i cibi preparati
Dare chiare indicazioni sul contenuto di sale dei cibi
Ostacolare i consumi di cibi e bevande ad alto contenuto di sale
Garantire che i cibi a basso contenuto di sale siano qualitativamente
i migliori, economicamente accessibili e disponibili ovunque
2916 Mo
The ISH and WHL Executive Boards, J Hypertens 2014; 32: 446-447
Daily sodium and potassium excretion in an Italian cohort of adult
individuals - Data from the MINISAL Study Program
Sodium excretion
Potassium excretion
n
mmol/day
Salt (gr)
> WHO
recomm. (%)
Men
1114
189
10.9
97
Women
1098
147
8.5
87
n
mmol/day
K+ (gr)
< WHO
recomm. (%)
Men
1114
63
2.5
96
Women
1098
55
2.1
99
Data from 2216 adult individuals (age range 35-79) from 12 Italian regions
Recommended sodium intake 85 mmol = 2 gr of sodium and 5 gr of salt and 100 mmol potrassium = 3.8 gr
2923 Mo
Donfrancesco C et al., Nutr Metab Cardiovasc Dis 2013; 23: 850-856
Association between BMI and
daily urinary sodium and potassium excretion in men
250
24h urinary sodium
mmol/24h
200
150
100
24h urinary potassium
50
0
1
2
3
4
5
BMI quintiles
2915 Mo
Donfrancesco C et al., Nutr Metab Cardiovasc Dis 2013; 23: 850-856
Increased risk of death related to a 6 g/day increase in salt intake
CHD death
CVD death
All death
1.75
***
Hazard Ratio
1.50
***
1.25
1.00
***
Lower salt intake
Higher salt intake
0.75
0.50
Data from 2436 individuals (age range 25-64 yrs) adjusted for age, smoking, cholesterol, SBP and BMI
*** p < 0.001 compared to lower salt intake
2927 Mo
Tuomilehto J et al., Lancet 2001; 357: 848-851
Projected effects of reducing salt intake by 3 gr/day in US
CHD:
60.000-120.000 less
Stroke:
32.000- 66.000 less
MI:
54.000- 99.000 less
Death from any cause:
44.000- 92.000 less
QA life years:
194.000-392.000 less
Cost saving:
10-24 billions
Data are calculated as new cases/year
2918 Mo
Bobbins-Domingo K et al., NEJM 2010; 362: 590-599