Another Major Role for Dietary Sodium Reduction

Abstract

Resistant hypertension, defined as blood pressure (BP) above goal in spite of the current use of 3 antihypertensive agents of different classes, is a common problem in general medical practice as well as specialty hypertension clinics.1 The prevalence of resistant hypertension is uncertain. Recent trials suggest a prevalence of 20% to 30%,2 which might be an overestimate because of selection procedures and enrollment criteria. If one applies a prevalence of 10% to the estimated 65 million Americans with hypertension, then ≈6.5 million Americans have resistant hypertension. The cause of this condition is almost always multifactorial. Common factors include lifestyle factors (eg, excess sodium intake, obesity, high alcohol intake), drug-related causes (eg, non-narcotic analgesics, sympathetic agents), and secondary causes of hypertension (eg, obstructive sleep apnea, primary aldosteronism, chronic kidney disease, and renal artery stenosis). In contrast to most of these conditions, a high sodium intake is ubiquitious and provides an opportunity to improve BP control, even when other factors coexist. Evidence linking salt (sodium chloride) intake with elevated BP is substantial and indisputable. Sodium reduction has been shown to lower BP in persons with prehypertension, untreated Stage 1 hypertension, and medication-treated hypertension.3 The effects of sodium reduction in hypertensive individuals on multiple medications, with or without controlled BP, has received scant attention, probably because of challenges related to accrual of participants and ethical issues related to prolonged assignment to a high-sodium control condition. In this issue of Hypertension , Pimenta and colleagues document the benefits of sodium reduction in patients with resistant hypertension.4 Pimenta and colleagues are to be congratulated for designing and implementing this challenging but informative and likely influential study. One cannot overestimate the logistical difficulties of recruiting eligible and interested participants, feeding them every meal over an extended …