Physicians' Academy for Cardiovascular Education

Higher sodium and lower potassium intakes associated with increased CV risk

24-Hour Urinary Sodium and Potassium Excretion and Cardiovascular Risk

Literature - Ma Y, He FJ, Sun Q et al. - N Engl J Med. 2021, doi: 10.1056/NEJMoa2109794

Introduction and methods


There are controversial findings on the association between sodium intake and CV risk. Both estimated lower and higher sodium intakes have been linked to increased CV risk [1-4]. This may be due to methodologic limitations, which include inaccurate estimates of individual sodium intakes and reverse causation related to coexisting conditions or changes in health status [5].

Because sodium and potassium are interrelated [6], the associations with CV risk were jointly examined.

In this study, the relationship between sodium and potassium intakes and CV risk were examined by combining individual-level data from studies in healthy populations in which multiple 24-h urine sample were obtained for each participant.

Study design

Individual data from six cohorts were combined. 10,709 Participants who had at least two 24-h urine samples at baseline were included. Sodium and potassium excretions were assessed by averaging the excretions in all available 24-h urine samples per participant.

Primary outcome

The primary outcome was a CV event, defined as the composite of coronary revascularization, fatal or nonfatal MI, or fatal or nonfatal stroke. The primary analysis excluded the first year of follow-up, because dietary information collected close to an event may not reflect habitual sodium intake. Median follow-up was 8.8 years (IQR: 7.6-10.9).

Main results

Sodium results

Potassium results

Sodium-potassium ratio results


This study using measurements of multiple 24-h urine samples showed that there was a linear relationship between sodium intake and CV risk, with a higher CV risk with higher sodium intake. On the contrary, higher potassium intake was associated with a lower CV risk


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