Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: Prospective cohort study

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Abstract

Objective: To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. Design: International prospective cohort study. Setting: 18 high, middle, and low income countries, sampled from urban and rural communities. Participants: 103 570 people who provided morning fasting urine samples. Main outcome measures: Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). Results: Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). Conclusions: These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.

Original languageEnglish
Article numberl772
JournalBMJ (Online)
Volume364
DOIs
Publication statusPublished - 1 Jan 2019
Externally publishedYes

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Potassium
Cohort Studies
Sodium
Prospective Studies
Mortality
Joints
Rural Population
Fasting
Outcome Assessment (Health Care)
Urine

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality : Prospective cohort study. / PURE investigators.

In: BMJ (Online), Vol. 364, l772, 01.01.2019.

Research output: Contribution to journalArticle

@article{3cab154ad7d04c0d819606f6a01efd72,
title = "Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality: Prospective cohort study",
abstract = "Objective: To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. Design: International prospective cohort study. Setting: 18 high, middle, and low income countries, sampled from urban and rural communities. Participants: 103 570 people who provided morning fasting urine samples. Main outcome measures: Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). Results: Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1{\%}) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002{\%} had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9{\%} of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4{\%} of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8{\%} of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3{\%} of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6{\%} of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). Conclusions: These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.",
author = "{PURE investigators} and Martin O'Donnell and Andrew Mente and Sumathy Rangarajan and McQueen, {Matthew J.} and Neil O'Leary and Lu Yin and Xiaoyun Liu and Sumathi Swaminathan and Rasha Khatib and Annika Rosengren and John Ferguson and Andrew Smyth and Patricio Lopez-Jaramillo and Rafael Diaz and Alvaro Avezum and Fernando Lanas and Ismail, {Noor Hassim} and Khalid Yusoff and Antonio Dans and Romaina Iqbal and Andrzej Szuba and Noushin Mohammadifard and Atyekin Oguz and Yusufali, {Afzal Hussein} and Alhabib, {Khalid F.} and Kruger, {Iolanthe M.} and Rita Yusuf and Jephat Chifamba and Karen Yeates and Gilles Dagenais and Andreas Wielgosz and Lear, {Scott A.} and Koon Teo and Salim Yusuf",
year = "2019",
month = "1",
day = "1",
doi = "10.1136/bmj.l772",
language = "English",
volume = "364",
journal = "The BMJ",
issn = "0959-8146",
publisher = "BMJ Publishing Group",

}

TY - JOUR

T1 - Joint association of urinary sodium and potassium excretion with cardiovascular events and mortality

T2 - Prospective cohort study

AU - PURE investigators

AU - O'Donnell, Martin

AU - Mente, Andrew

AU - Rangarajan, Sumathy

AU - McQueen, Matthew J.

AU - O'Leary, Neil

AU - Yin, Lu

AU - Liu, Xiaoyun

AU - Swaminathan, Sumathi

AU - Khatib, Rasha

AU - Rosengren, Annika

AU - Ferguson, John

AU - Smyth, Andrew

AU - Lopez-Jaramillo, Patricio

AU - Diaz, Rafael

AU - Avezum, Alvaro

AU - Lanas, Fernando

AU - Ismail, Noor Hassim

AU - Yusoff, Khalid

AU - Dans, Antonio

AU - Iqbal, Romaina

AU - Szuba, Andrzej

AU - Mohammadifard, Noushin

AU - Oguz, Atyekin

AU - Yusufali, Afzal Hussein

AU - Alhabib, Khalid F.

AU - Kruger, Iolanthe M.

AU - Yusuf, Rita

AU - Chifamba, Jephat

AU - Yeates, Karen

AU - Dagenais, Gilles

AU - Wielgosz, Andreas

AU - Lear, Scott A.

AU - Teo, Koon

AU - Yusuf, Salim

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Objective: To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. Design: International prospective cohort study. Setting: 18 high, middle, and low income countries, sampled from urban and rural communities. Participants: 103 570 people who provided morning fasting urine samples. Main outcome measures: Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). Results: Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). Conclusions: These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.

AB - Objective: To evaluate the joint association of sodium and potassium urinary excretion (as surrogate measures of intake) with cardiovascular events and mortality, in the context of current World Health Organization recommendations for daily intake (<2.0 g sodium, >3.5 g potassium) in adults. Design: International prospective cohort study. Setting: 18 high, middle, and low income countries, sampled from urban and rural communities. Participants: 103 570 people who provided morning fasting urine samples. Main outcome measures: Association of estimated 24 hour urinary sodium and potassium excretion (surrogates for intake) with all cause mortality and major cardiovascular events, using multivariable Cox regression. A six category variable for joint sodium and potassium was generated: sodium excretion (low (<3 g/day), moderate (3-5 g/day), and high (>5 g/day) sodium intakes) by potassium excretion (greater/equal or less than median 2.1 g/day). Results: Mean estimated sodium and potassium urinary excretion were 4.93 g/day and 2.12 g/day, respectively. After a median follow-up of 8.2 years, 7884 (6.1%) participants had died or experienced a major cardiovascular event. Increasing urinary sodium excretion was positively associated with increasing potassium excretion (unadjusted r=0.34), and only 0.002% had a concomitant urinary excretion of <2.0 g/day of sodium and >3.5 g/day of potassium. A J-shaped association was observed of sodium excretion and inverse association of potassium excretion with death and cardiovascular events. For joint sodium and potassium excretion categories, the lowest risk of death and cardiovascular events occurred in the group with moderate sodium excretion (3-5 g/day) and higher potassium excretion (21.9% of cohort). Compared with this reference group, the combinations of low potassium with low sodium excretion (hazard ratio 1.23, 1.11 to 1.37; 7.4% of cohort) and low potassium with high sodium excretion (1.21, 1.11 to 1.32; 13.8% of cohort) were associated with the highest risk, followed by low sodium excretion (1.19, 1.02 to 1.38; 3.3% of cohort) and high sodium excretion (1.10, 1.02 to 1.18; 29.6% of cohort) among those with potassium excretion greater than the median. Higher potassium excretion attenuated the increased cardiovascular risk associated with high sodium excretion (P for interaction=0.007). Conclusions: These findings suggest that the simultaneous target of low sodium intake (<2 g/day) with high potassium intake (>3.5 g/day) is extremely uncommon. Combined moderate sodium intake (3-5 g/day) with high potassium intake is associated with the lowest risk of mortality and cardiovascular events.

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DO - 10.1136/bmj.l772

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JF - The BMJ

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