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颠覆！柳叶刀：少吃盐没啥用，无法降低心衰患者死亡风险！

2022-06-10 Swagpp MedSci原创

心力衰竭柳叶刀低钠
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柳叶刀：减少钠摄入量无法改善心衰患者全因死亡、因心血管原因而急诊或住院的风险，但患者的整体生活质量及心衰严重程度得到了一定的提高。

盐，是生活中必不可少的一种调味料，没了盐很多菜肴都会失去灵魂。但所谓“有一利必有一弊”，过量的食盐摄入也会对健康产生消极影响。因此，世界卫生组织建议，每人每日食盐摄入量不应超过5g。
 
在全球范围内，中国是食盐摄入量最高的国家之一。美国心脏协会杂志（Journal of the American Heart Association）上一项系统综述显示，在过去的近40年内，中国人的钠摄入量远高于世界卫生组织的推荐，换算成食盐的摄入量则达到推荐最高摄入量的2倍！
 
图片

中国成人平均24小时尿钠排泄的时间趋势

 
钠是盐的主要成分之一，减盐更多关注的是减钠。今年5月，世界高血压联盟（WHL）发布了“关于减少饮食中钠（盐）摄入量”的全球行动倡议，指出据全球疾病负担研究估计，仅2019年饮食中过量钠摄入导致超过180万的死亡病例，而饮食中钠的摄入量减少30%可在25年内预防全球4000万人死亡！
 
一直以来，饮食限制钠被认为是防止体液超负荷、改善心衰患者临床结果的一大机制，100多年来也作为饮食建议之一提供给心脏病患者。
 
然而，支持这一建议的随机对照临床试验证据并不多。限制心衰患者的饮食钠真的有必要吗？是否可以改善患者的临床结局呢？
 
来自加拿大的研究学者开展了一项迄今规模最大的减少钠摄入量与心力衰竭关系的随机对照临床试验，涵盖6个国家的参与者。结果发现，减少钠摄入量无法改善心衰患者全因死亡、因心血管原因而急诊或住院的风险，但患者的整体生活质量及心衰严重程度得到了一定的提高。这项“颠覆认知”的研究发表在柳叶刀上。
 
图片
https://doi.org/10.1016/S0140-6736(22)00369-5
 
2014年3月至2020年12月期间，研究者从澳大利亚、加拿大、智利、哥伦比亚、墨西哥和新西兰的26个地点共招募到806名成年慢性心衰患者（定义为NYHA心功能分级2-3级），并被以1:1的比例随机分配至低钠饮食组（n=397人）或常规护理组（n=409人），两组患者的基线特征相匹配。
 
患者每日的饮食由专业营养师指导，总热量在正常范围内，三大营养素的占比分别为：蛋白质15-20%，碳水化合物50-55%，脂肪25-30%，饱和脂肪7%，与大多数心血管饮食指南一致。总干预时长为12个月，再加上12个月随访。
 
入组时，低钠饮食组的钠摄入量中位数为2286mg/天，而常规护理组为2119mg/天，不具有统计学差异。
 
干预过程中，6个月时，低钠饮食组的钠摄入量中位数为1649mg/天，而常规护理组为2021mg/天。
 
12个月时，低钠饮食组的钠摄入量中位数为1658mg/天，而常规护理组为2073mg/天。常规护理组的钠摄入量比低钠饮食组高出415mg/天，组间差异显著（p<0.01）。
 
但在长达一年的干预中，两组在体重、收缩压、总能量摄入等方面没有显著差异。
 
图片
两组的钠摄入量、血压、体重和能量摄入量的变化
 
对比两组在干预过程中疾病情况发现，12个月中，低钠饮食组的397名患者中，有60名出现了心血管相关住院或急诊以及全因死亡的情况，占比为15%。
 
而常规护理组的409名患者中，有70名出现了相似状况，占比为17%，与低钠饮食组相比没有统计学差异。
 
低钠饮食组和常规护理组中，分别有22例和17例发生了全因死亡，有40例和51例因心血管原因而住院，有17例和15例患者因心血管原因去医院急诊，组间均无显著差异（p>0.05）。也就是说，低钠饮食并不会降低心衰患者急诊、住院及死亡的风险。
 
图片
组间复合结局、全因死亡率、心血管相关住院、心血管相关急诊的区别
 
不过，在干预期间，低钠饮食组的生活质量评分有了明显改善，患者的堪萨斯城心肌病调查问卷（KCCQ）评分的增加高于常规护理组。
 
根据基线调整后，12个月干预结束的低钠饮食组KCCQ综合评分增加了3.38分，临床总结得分增加了3.29分，身体极限评分增加了3.77分。
 
此外，干预后，两组间的NYHA心功能等级产生了统计学差异，低钠饮食组比常规护理组更有可能改善一个NYHA等级，即降低膳食钠的摄入能让患者的心力衰竭程度得到持续改善。
 
图片
两组间生活质量评分及心衰程度等级变化
 
本研究的第一作者Justin A Ezekowitz教授表示，我们不能像之前那样认为，减少钠盐摄入量能降低所有心脏病患者的住院或死亡风险，只能说这一做法能够提高心衰患者的整体生活质量。
 
虽然心脏病相关的临床结果没有显著变化，但科学家认为，继续坚持建议心衰患者控制钠盐摄入量仍是利大于弊。
 
不过，本研究也存在一定的局限性，包括没有对患者采用盲法导致偏倚的存在、没有收集患者尿液或其他生物标志物的数据、干预和随访的时间有限等等。但研究者也将进一步对参与者进行为期24个月和5年的随访，以确认减少饮食钠摄入是否能维持长期的健康益处。
 

参考资料：

[1]Tan M, He FJ, Wang C, MacGregor GA. Twenty-Four-Hour Urinary Sodium and Potassium Excretion in China: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2019 Jul 16;8(14):e012923. doi: 10.1161/JAHA.119.012923. Epub 2019 Jul 11. PMID: 31295409; PMCID: PMC6662145.
[2]Ezekowitz JA, Colin-Ramirez E, Ross H, Escobedo J, Macdonald P, Troughton R, Saldarriaga C, Alemayehu W, McAlister FA, Arcand J, Atherton J, Doughty R, Gupta M, Howlett J, Jaffer S, Lavoie A, Lund M, Marwick T, McKelvie R, Moe G, Pandey AS, Porepa L, Rajda M, Rheault H, Singh J, Toma M, Virani S, Zieroth S; SODIUM-HF Investigators. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial. Lancet. 2022 Apr 9;399(10333):1391-1400. doi: 10.1016/S0140-6736(22)00369-5. Epub 2022 Apr 2. PMID: 35381194.

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    2023-03-11 sunylz

    #患者死亡#

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    2022-06-11 quxin068

    #死亡风险#

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    2022-06-11 yuanming7

    #心衰患者#

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1983776, encodeId=27181983e7699, content=<a href='/topic/show?id=628553048e3' target=_blank style='color:#2F92EE;'>#患者死亡#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53048, encryptionId=628553048e3, topicName=患者死亡)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=12de429, createdName=sunylz, createdTime=Sat Mar 11 02:19:21 CST 2023, time=2023-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1256208, encodeId=c9721256208df, content=<a href='/topic/show?id=587f6339050' target=_blank style='color:#2F92EE;'>#死亡风险#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63390, encryptionId=587f6339050, topicName=死亡风险)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=74808, createdName=quxin068, createdTime=Sat Jun 11 09:19:21 CST 2022, time=2022-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1373567, encodeId=c1da13e35679b, content=<a href='/topic/show?id=2fd051939ab' target=_blank style='color:#2F92EE;'>#心衰患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51939, encryptionId=2fd051939ab, topicName=心衰患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=467c360, createdName=yuanming7, createdTime=Sat Jun 11 09:19:21 CST 2022, time=2022-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225703, encodeId=1bed1225e039f, content=希望有更多的類似觀察有助加深對某些生活飲食習慣的重要性, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a3a85623640, createdName=ms6000000088395420, createdTime=Fri Jun 10 19:16:08 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225690, encodeId=6a021225690ce, content=好处还是大于坏处。, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210703/9c448fe1b3b54fd7bc9477662f4861bb/4bdadad22bfd46f2921aabb4c40265d3.jpg, createdBy=a8d81938466, createdName=weigq, createdTime=Fri Jun 10 17:19:01 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225580, encodeId=50311225580ab, content=认真学习～～, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cfb41991958, createdName=xulv123, createdTime=Fri Jun 10 08:40:06 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225577, encodeId=464412255e798, content=不错的文章, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b0825417521, createdName=ms6000000960504356, createdTime=Fri Jun 10 08:04:19 CST 2022, time=2022-06-10, status=1, ipAttribution=)]
    2022-06-10 ms6000000088395420

    希望有更多的類似觀察有助加深對某些生活飲食習慣的重要性

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1983776, encodeId=27181983e7699, content=<a href='/topic/show?id=628553048e3' target=_blank style='color:#2F92EE;'>#患者死亡#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53048, encryptionId=628553048e3, topicName=患者死亡)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=12de429, createdName=sunylz, createdTime=Sat Mar 11 02:19:21 CST 2023, time=2023-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1256208, encodeId=c9721256208df, content=<a href='/topic/show?id=587f6339050' target=_blank style='color:#2F92EE;'>#死亡风险#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63390, encryptionId=587f6339050, topicName=死亡风险)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=74808, createdName=quxin068, createdTime=Sat Jun 11 09:19:21 CST 2022, time=2022-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1373567, encodeId=c1da13e35679b, content=<a href='/topic/show?id=2fd051939ab' target=_blank style='color:#2F92EE;'>#心衰患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51939, encryptionId=2fd051939ab, topicName=心衰患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=467c360, createdName=yuanming7, createdTime=Sat Jun 11 09:19:21 CST 2022, time=2022-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225703, encodeId=1bed1225e039f, content=希望有更多的類似觀察有助加深對某些生活飲食習慣的重要性, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a3a85623640, createdName=ms6000000088395420, createdTime=Fri Jun 10 19:16:08 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225690, encodeId=6a021225690ce, content=好处还是大于坏处。, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210703/9c448fe1b3b54fd7bc9477662f4861bb/4bdadad22bfd46f2921aabb4c40265d3.jpg, createdBy=a8d81938466, createdName=weigq, createdTime=Fri Jun 10 17:19:01 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225580, encodeId=50311225580ab, content=认真学习～～, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cfb41991958, createdName=xulv123, createdTime=Fri Jun 10 08:40:06 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225577, encodeId=464412255e798, content=不错的文章, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b0825417521, createdName=ms6000000960504356, createdTime=Fri Jun 10 08:04:19 CST 2022, time=2022-06-10, status=1, ipAttribution=)]
    2022-06-10 weigq

    好处还是大于坏处。

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1983776, encodeId=27181983e7699, content=<a href='/topic/show?id=628553048e3' target=_blank style='color:#2F92EE;'>#患者死亡#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53048, encryptionId=628553048e3, topicName=患者死亡)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=12de429, createdName=sunylz, createdTime=Sat Mar 11 02:19:21 CST 2023, time=2023-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1256208, encodeId=c9721256208df, content=<a href='/topic/show?id=587f6339050' target=_blank style='color:#2F92EE;'>#死亡风险#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=63390, encryptionId=587f6339050, topicName=死亡风险)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=74808, createdName=quxin068, createdTime=Sat Jun 11 09:19:21 CST 2022, time=2022-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1373567, encodeId=c1da13e35679b, content=<a href='/topic/show?id=2fd051939ab' target=_blank style='color:#2F92EE;'>#心衰患者#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51939, encryptionId=2fd051939ab, topicName=心衰患者)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=467c360, createdName=yuanming7, createdTime=Sat Jun 11 09:19:21 CST 2022, time=2022-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225703, encodeId=1bed1225e039f, content=希望有更多的類似觀察有助加深對某些生活飲食習慣的重要性, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a3a85623640, createdName=ms6000000088395420, createdTime=Fri Jun 10 19:16:08 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225690, encodeId=6a021225690ce, content=好处还是大于坏处。, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210703/9c448fe1b3b54fd7bc9477662f4861bb/4bdadad22bfd46f2921aabb4c40265d3.jpg, createdBy=a8d81938466, createdName=weigq, createdTime=Fri Jun 10 17:19:01 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225580, encodeId=50311225580ab, content=认真学习～～, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cfb41991958, createdName=xulv123, createdTime=Fri Jun 10 08:40:06 CST 2022, time=2022-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1225577, encodeId=464412255e798, content=不错的文章, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=b0825417521, createdName=ms6000000960504356, createdTime=Fri Jun 10 08:04:19 CST 2022, time=2022-06-10, status=1, ipAttribution=)]
    2022-06-10 xulv123

    认真学习～～

    0

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    2022-06-10 ms6000000960504356

    不错的文章

    0

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