CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 AFRICA 121 pulmonary bypass. Ann Thorac Surg 2000; 69: 1471–1475. 27. Hirose H, Amano A, Takahashi A. Off-pump coronary artery bypass grafting for elderly patients. Ann Thorac Surg 2001; 72: 2013–2019. 28. Goto T, Baba T, Matsuyama K, Honma K, Ura M, Koshiji T, et al. Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients. Ann Thorac Surg 2003; 75: 1912–1918. 29. Murphy GJ, Angelini GD. Side effects of cardiopulmonary bypass: what is the reality? J Card Surg 2004; 19: 481–488. 30. Uyar IS, Akpınar MB, Sahin V, Abacilar F, Yurtman V, Okur FF, et al. Effects of single aortic clamping versus partial aortic clamping techniques on post-operative stroke during coronary artery bypass surgery. Cardiovasc J Afr 2013; 24: 213–217. 31. Zhao DF, Edelman JJ, Seco M, Bannon PG, Wilson MK, Byrom MJ, et al. Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network meta-analysis. J Am Coll Cardiol 2017; 69(8): 924–936. 32. Tugtekin S, Kappert U, Alexiou K, Wilbring M, Nagpal AD, Matschke K. Coronary artery bypass grafting in octogenarians outcome with and without extracorporial circulation. Thorac Cardiovasc Surg 2007; 55: 407–411. 33. Ricotta JJ, Faggioli GL, Castilone A, Hasset JM. Buffalo CardiacCerebral study group. Risk factors for stroke after cardiac surgery. J Vasc Surg 1995; 21: 359–364. 34. Harrison MJ. Neurologic complications of coronary artery bypass grafting: diffuse or focal ischemia? Ann Thorac Surg 1995; 59: 1356–1358. 35. Sternby NH. Atherosclerosis in a defined population. An autopsy survey in Malmo, Sweden. Acta Pathol Microbiol Scand 1968; 194(suppl): 1–216. Sodium restriction in heart failure should be taken with a pinch of salt The time-worn, standard injunction against low-salt consumption in heart failure is not borne out by the evidence, writes MedicalBrief. The SODIUM-HF trial, conducted at 26 sites in six countries over six years, concludes that dietary intervention to reduce sodium intake did not reduce clinical events. Therapy for heart failure has come a long way in a short time, writes Dr John Mandrola in Medscape. Yet clinicians place substantial burden on patients with chronic heart failure, asking them to take numerous medicines, make frequent appointments, exercise and eat well. Strict sodium restriction is one of those burdens. He writes: at the American College of Cardiology (ACC) 2022 Scientific Session (2 April), Justin Ezekowitz, from the University of Alberta, Canada, presented results of the SODIUM-HF trial, which put this common recommendation to the test of randomisation. The Lancet simultaneously published the study. Before SODIUM-HF, there was little to no supportive evidence for strict sodium restriction. A systematic review of nine studies found no consistent benefit of low-sodium regimens. SODIUM-HF is a pragmatic randomised, controlled trial that tested general advice on dietary sodium against a low-sodium diet of 1 500 mg daily. Unlike drug trials, which can strictly control active and treatment arms in a relatively optimal setting, pragmatic trials test interventions in the real world. This difference influences how we interpret and apply the trial results. Patients in SODIUM-HF had class II–III NewYork Heart Association heart failure and were recruited mostly from primary care settings. They were typical of out-patients with heart failure: average age 66 years, average left ventricular ejection fraction of 36%, good medical therapy. The study was carried out in 26 sites in six countries over six years. Food and menus were individualised to local region and country. About 400 patients were in each arm. The primary endpoint was a composite of all-cause death and hospitalisation or emergency department visit for cardiovascular (CV) reasons. The average sodium intake, as measured by three-day food records, was approximately 2 000 mg/day in the control group and about 1 600 mg/day in the low-sodium arm. A primary outcome occurred in 15% of the low-sodium arm versus 17% of the control arm, which did not meet statistical significance (hazard ratio 0.89; 95% CI: 0.69–1.26; p = 0.53). Death, CV hospitalisations and CV emergency department visits did not differ significantly between groups. Patients in the low-sodium arm scored significantly better on the Kansas City Cardiomyopathy Questionnaire, which measures a person’s perception of their health. A caveat here is that the trial was open-label, so a placebo effect is possible. The authors concluded with just one spin-free sentence: ‘In ambulatory patients with heart failure, a dietary intervention to reduce sodium intake did not reduce clinical events.’ Comments Since the results and conclusions were so clear, let’s discuss the trial’s limitations, which influence how we translate this finding to the care of patients. At ACC and online, SODIUM-HF endured some pushback. It stirred a defensive urge in me. When a trial fails to find a significant difference between treatment arms, there are two possibilities: one is that there was actually no difference (true negative), and the other is that there was a difference, but the trial did not detect it (false negative). continued on page 136…
RkJQdWJsaXNoZXIy NDIzNzc=