January 30, 2013
Volume 8 - Issue 5     

DynaMed Weekly Update

For the week ending January 25, 2013

Last week 452 articles were evaluated via DynaMed's Systematic Literature Surveillance and 195 were added to DynaMed content.   


Based on the editors' criteria of selecting "articles most likely to change clinical practice," one article of significant interest was selected for the DynaMed Weekly Update.

Feature Article

Low Sodium Diets Increase Mortality and Readmission Rate in Patients with Systolic Heart Failure Taking Daily Diuretics 

Guidelines from the Heart Failure Society of America (HFSA) recommend daily sodium intake of 2-3 g in most patients with heart failure, and suggest limiting sodium intake to < 2 g daily in cases of moderate-severe heart failure (J Card Fail 2010 Jun;16(6):e1).  These recommendations have been based largely on observational data.  A Cochrane review in 2011 identified a single randomized trial evaluating low sodium diets in patients with heart failure taking high-dose furosemide, and found an association between low sodium and increased mortality (Cochrane Database Syst Rev 2011 Jul 6;(7):CD009217).  A new systematic review compared low sodium vs. normal sodium diets with data from 6 randomized trials including 2,747 patients with heart failure with a broader mix of diuretic treatment dosages.


In all trials, patients were randomized to a low-sodium diet of 1.8 grams daily vs. a normal sodium diet of 2.8 grams daily.  Most trials had a fluid restriction for all patients of 1 liter daily.  Furosemide doses (IV or oral) ranged from a low of 50-125 mg twice daily in 1 trial with 1,771 patients to a high of 500-1000 mg twice daily in 2 trials.


Compared to normal sodium diets, low sodium diets significantly increased all-cause mortality (risk ratio [RR] 1.95, 95% CI 1.66-2.29), heart failure-related mortality (RR 2.23, 95% CI 1.77-2.81) and heart failure readmissions (RR 2.1, 95% CI 1.67-2.64) (level 1 [likely reliable] evidence).  The numbers needed to harm (NNH) were 6-12 for all-cause mortality and 2-7 for readmission.  Low sodium diets were also associated with increased risk of sudden death (RR 1.72, 95% CI 1.21-2.44) (Heart 2013 Jan 24 early online). 


In the largest trial, with the most clinically applicable furosemide dosing, the low sodium diet was associated with increased mortality (23.8% vs. 12.9%, p < 0.0001, NNH 9) and increased heart failure readmissions (34.2% vs. 18.5%, p < 0.0001, NNH 6) in follow-up of 57 months.  In this trial, the normal sodium group received hypertonic saline solution 150 mL with each furosemide infusion (Am J Med Sci 2011 Jul;342(1):27).


For more information, see the Heart failure topic in DynaMed.  

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DynaMed Announcement  
Debuting next week, the DynaMed Weekly Update is changing its name to DynaMed EBM Focus. It will offer the same practice changing articles you've come to expect, but in a new, more intuitive format.
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About DynaMed Weekly Update

Prepared by the clinician members of the DynaMed Editorial Team, DynaMed Weekly Update is a compilation of one to five articles selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice.

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CME Information


0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
Release Date: January 30, 2013
Expiration Date: January 30, 2014
Estimated Completion Time:
15 minutes
There is no fee for this activity.

To Receive Credit 
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives


Upon successful completion of this educational program, the reader should be able to:


1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.


Faculty Information
Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.


No commercial support has been received for this activity.

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AAFP: Enduring Material activity, DynaMed Weekly Update, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each Weekly Update is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.


Program ID: 1210392V

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