Heterogeneity in Treatment Effects in the Reduction of Dietary Sodium to Less Than 100 mmol in Heart Failure (SODIUM-HF): A Secondary Post Hoc Analysis

Fernando G Zampieri; Sarah Rathwell; Finlay A McAlister; Heather Ross; Jorge Escobedo; Clara Saldarriaga; Eloisa Colin-Ramirez; Richard W Troughton; Peter Macdonald; Wendimagegn Alemayehu; Justin A Ezekowitz; SODIUM-HF Investigators

doi:10.1016/j.cardfail.2025.01.027

Heterogeneity in Treatment Effects in the Reduction of Dietary Sodium to Less Than 100 mmol in Heart Failure (SODIUM-HF): A Secondary Post Hoc Analysis

J Card Fail. 2026 Feb;32(2):371-381. doi: 10.1016/j.cardfail.2025.01.027. Epub 2025 Mar 3.

Affiliations

¹ Department of Critical Care Medicine, Faculty of Medicine & Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada.
² Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
³ Peter Munk Cardiac Centre, Toronto, Ontario, Canada.
⁴ Instituto Mexicano del Seguro Social, Mexico City, Mexico.
⁵ Centro Cardiovascular Colombiano Clinica Santa Maria (Clinica Cardio VID), Antioquia, Colombia.
⁶ Dirección de Nutrición, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
⁷ University of Otago, Christchurch, New Zealand.
⁸ St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.
⁹ Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada. Electronic address: jae2@ualberta.ca.

PMID: 40043831
DOI: 10.1016/j.cardfail.2025.01.027

Abstract

Background: SODIUM-HF (Study of Dietary Intervention of Sodium Under100 mmol in Heart Failure) compared usual care with dietary sodium restriction in patients with heart failure (HF) and produced neutral results for the primary endpoint. Heterogeneity in treatment effects (HTE) analysis could enhance the original findings.

Objective: Explore the presence of HTE in the SODIUM-HF trial using a risk-effect-based approach.

Methods: HTE was assessed using a risk-based approach based on the Meta-Analysis Global Group in Chronic (MAGGIC) HF risk score. Interaction between MAGGIC quartiles and outcomes was assessed using a Bayesian regression model with neutral priors. The primary endpoint was the same for the original trial (composite of cardiovascular-related admission to hospital, cardiovascular-related emergency department visit, or all-cause death within 12 months in the intention-to-treat population); KCCQ was the secondary endpoint.

Results: Were included 806 patients. MAGGIC quartiles used for the risk-based analyses were 0.036 to 0.102 (low), >0.102 to 0.147 (medium-low), >0.147 to 0.209 (medium-high), and >0.209 to 0.591 (high). There was very strong evidence for the interaction between MAGGIC quartile and intervention (Bayes factor of 68). There was a strong suggestion of association between intervention arm and a lower occurrence of the primary endpoint for the medium-low MAGGIC quartile (>0.98 probability), and a suggestion that the intervention was associated with more frequent occurrence of the primary endpoint in the high MAGGIC quartile (probability of benefit of 0.06). Suggestion of HTE was also found for KCCQ with a strong suggestion of benefit for the intervention for those in the lowest MAGGIC quartiles.

Conclusions: HTE effects in the SODIUM-HF trial is probable. Further trials in sodium retention may benefit by incorporating this information.

Keywords: Nutrition; heart failure; heterogeneity in treatment effects; salt restriction.

Publication types

Randomized Controlled Trial

MeSH terms

Aged
Diet, Sodium-Restricted* / methods
Female
Heart Failure* / diagnosis
Heart Failure* / diet therapy
Humans
Male
Middle Aged
Sodium, Dietary* / administration & dosage
Treatment Effect Heterogeneity
Treatment Outcome

Substances

Sodium, Dietary