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High salt diet associated with hardened arteries even in people with normal blood pressure

Nutrition, Malnutrition and Heart Disease
Risk Factors and Prevention

Sophia Antipolis, 31 March 2023:  Eating excessive salt is linked with clogged arteries of the heart and neck, which is known to be linked with raised risks of heart attack and stroke. That’s the finding of a study published today in European Heart Journal – Open, a journal of the European Society of Cardiology.1

Atherosclerosis is a narrowing of the arteries with deposits called plaque. Blood flow is impaired in arteries supplying the heart and brain with blood, raising the risks of heart attack and stroke.

“This was the first study to examine the association between a high salt intake and atherosclerosis in both the heart and neck arteries,” said study author Dr. Jonas Wuopio of the Karolinska Institutet, Huddinge and Clinical Research Center, Falun, Uppsala University, Sweden. “The association was linear, meaning that each rise in salt intake was linked with more atherosclerosis. The findings applied even at normal blood pressure levels, suggesting that salt could be damaging even before the development of hypertension.”

“The results reinforce the advice from the World Health Organization and other medical societies to minimise salt intake to about a teaspoon a day,” he continued.2 “It’s hard to estimate how much salt we eat, so I have two tricks to help lower consumption. One is to limit the use of table salt, as this has been linked with cardiovascular health.3 Number two is to replace salt, which is 100% sodium chloride, with a salt substitute containing 70–80% sodium chloride and 20–30% potassium chloride. Well conducted studies have shown that this approach is beneficial for heart health.4

This analysis included 10,778 adults aged 50 to 64 years in the Swedish CArdioPulmonary bioImage Study (SCAPIS), the world’s largest general population study assessing coronary computed tomography angiography (CCTA). Urinary sodium excretion was measured to estimate salt consumption. CCTA was used to obtain 3D images of the heart arteries for two measurements. First, the amount of calcium in the arteries, summed up as the coronary artery calcium score (CACS) in five categories (0, 1-9, 10-99, 100-399, over 399), with a higher value indicating a greater risk of myocardial infarction. Second, obstructions (stenosis) of the heart vessels, classified as no stenosis, non-significant stenosis (less than 50% narrowing), and significant stenosis (more than 50% narrowing). Participants also had an ultrasound of the carotid arteries in the neck and were divided into three groups: no plaque, plaque in one vessel, and plaque in both vessels.

The average age of participants was 58 years and 52% were women. The researchers analysed the association between incremental increases in salt intake and atherosclerosis after adjusting for age, sex and study site. Rising salt consumption was linked with increasing atherosclerosis in a stepwise fashion in both the neck and heart arteries. Each 1,000 mg rise in sodium excretion was associated with a 3%, 4% and 4% higher likelihood of a more serious category in the carotid plaque, CACS and coronary artery stenosis measurements, respectively.

Dr. Wuopio said: “The results show that the more salt people eat, the higher the burden of  atherosclerotic plaques in the arteries of the heart and neck. The increase in blood pressure due to a high salt intake seems to be an important underlying mechanism for these findings. Interestingly, the results were consistent when we restricted our analyses to participants with normal blood pressure (below 140/90 mmHg) or to those without known cardiovascular disease. This means that it’s not just patients with hypertension or heart disease who need to watch their salt intake.”



References and notes
1Wuopio J, Ling YT, Orho-Melander M, et al. The association between sodium intake and coronary and carotid atherosclerosis in the general Swedish population. Eur Heart J Open. 2023. doi:10.1093/ehjopen/oead024.

2World Health Organization: Salt intake.

3Ma H, Xue Q, Wang X, et al. Adding salt to foods and hazard of premature mortality. Eur Heart J. 2022;43:2878–2888.

4Neal B, Wu Y, Feng X, et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med. 2021;385:1067–1077.

Accompanying editorial:
Banach M, Surma S. Dietary salt intake and atherosclerosis - an area not fully explored. Eur Heart J Open. 2023. doi:10.1093/ehjopen/oead025.

About the European Society of Cardiology 

The European Society of Cardiology brings together health care professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About the European Heart Journal – Open 
European Heart Journal – Open is dedicated to the entire spectrum of cardiovascular medicine, with emphasis on novel research results with the potential to improve patient care.

Notes to editor

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Funding: The main funding body of The Swedish CArdioPulmonary bioImage Study (SCAPIS) is the Swedish Heart-Lung Foundation. The study is also funded by the Knut and Alice Wallenberg Foundation, the Swedish Research Council and VINNOVA (Sweden’s Innovation agency) the University of Gothenburg and Sahlgrenska University Hospital, Karolinska Institutet and Stockholm county council, Linköping University and University Hospital, Lund University and Skåne University Hospital, Umeå University and University Hospital, Uppsala University and University Hospital.

Disclosures: Professor Johan Ärnlöv declares that he has received lecturing fees from AstraZeneca and Novartis and has served on advisory boards for AstraZeneca and Boehringer Ingelheim, unrelated to the present study. None of the other authors have any conflicts of interest to declare.