Older adult Chinese patients with normal blood pressure (BP) who replace salt with a salt substitute demonstrated reduced incidence of hypertension and no increase in hypotension episodes, a post hoc analysis of the DECIDE-Salt trial suggests. Xianghui Zhang, MSc, of Peking University First Hospital, Beijing, and the Shihezi University School of Medicine, Shanxi, China, and Yifang Yuan, MD, also of Peking University First Hospital, and colleagues, reported these results in a manuscript published Monday online and in the Feb. 20 issue of the Journal of the American College of Cardiology. Roughly 1.4 billion adults worldwide experience hypertension, the leading risk factor for cardiovascular disease (CVD). In China, 27.5% of adults live with hypertension, and this number continues to rise. One of the easiest ways to improve CV health is to reduce sodium intake, but few people follow-through on reducing their sodium. More effective and safe sodium-reduction strategies are needed worldwide. Potassium chloride is a salt substitute that replaces sodium chloride and may be a reasonable alternative to salt for those seeking to reduce their sodium intake. Few studies have investigated the effects of salt substitutes in populations with a healthy BP. “Adults frequently fall into the trap of consuming excess salt through easily accessible and budget-friendly processed foods,” said Yangfeng Wu, MD, PhD, lead author of the DECIDE-Salt study and executive director of Peking University Clinical Research Institute in Beijing, in a news release. “It's crucial to recognize the impact of our dietary choices on heart health and increase the public’s awareness of lower-sodium options." This post hoc analysis evaluated outcomes from the DECIDE-Salt (Diet Exercise and Cardiovascular Health-Salt Reduction Strategies for the Elderly in Nursing Homes in China) trial, a multicenter, cluster-randomized controlled investigation that took place for 2 years across 48 elderly care facilities. Participants with normal BP (<140/90 mm Hg) were included in this analysis. The risk of hypertension was compared using the frailty survival model, and the risk of hypotension episodes was compared using the generalized linear mixed model. Hypertension was the primary outcome of the present study, which was defined as ≥140/90 mm Hg BP at two or more follow-up visits, initiation of antihypertensive medications or major adverse cardiovascular events (coronary heart disease and stroke) at follow-up. Participants in the salt substitute group (n=313, mean age=71.0 years, 73.8% men) had lower rates of hypertension occurrence compared with the usual salt group (n=298, mean age=71.8 years, 74.8% men) (11.7 versus 24.3 per 100 person-years; adjusted hazard ratio [HR]=0.60; 95% confidence interval [CI]=0.39-0.92; p=0.02), and did not have an increased number of hypotension episodes (9.0 versus 9.7 per 100 person-years; p=0.76). In the salt-substitute group, mean systolic/diastolic BP did not increase between baseline and the end of the intervention, but it did increase in the usual-salt group (mean changes: 0.3±11.9/0.2±7.1 mm Hg versus 7.0±14.3/2.1±7.5 mm Hg). The net reduction of diastolic BP was -8.00 mm Hg (95% CI=12.4 to –3.7 mm Hg), and systolic was -2.00 mm Hg (95% CI=4.1 to 0.1 mm Hg) in the salt-substitute group as compared to the usual-salt group. Overall, these results demonstrate the potential of potassium chloride as a salt substitute for sodium chloride in healthy populations, and this salt substitute significantly reduced the risk of incident hypertension and did not increase the risk of hypotension in older Chinese adults. In an accompanying editorial, Rik H.G. Olde Engberink, MD, PhD, of the University of Amsterdam and Microcirculation, discussed the statistics on global hypertension and dietary impacts on hypertension, as well as the influence of salt intake and potential of salt substitutes. “Considering the failing strategy to reduce the intake of salt worldwide, salt substitution is an attractive alternative,” Engberink wrote. But the editorialist went on to caution that other groups who were not included in the study. “Because the largest studies have been performed in Asia, with a relatively low baseline potassium intake, one could argue whether a similar effect on outcome can be found in regions with higher potassium intake, such as Europe and North America... Another potential concern is subjects with chronic kidney disease, who have been excluded from most salt substitute trials.” The editorialist concluded by noting the importance of salt substitutes and that world health authorities should prepare to implement standards for the use of salt substitutes. Sources: Zhang X, Yuan Y, Li C, et al. Effect of a Salt Substitute on Incidence of Hypertension and Hypotension Among Normotensive Adults. J Am Coll Cardiol. 2024;83:711-722. Olde Engberink RHG. Salt Intake: Reduce or Substitute? J Am Coll Cardiol. 2024;83:723-725. Image Credit: Melica – stock.adobe.com