You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Can Salt Substitutes Reduce Cardiovascular Diseases, Stroke, and Death?

  • Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/14/2022
  • Valid for credit through: 10/14/2023, 11:59 PM EST
Start Activity

Target Audience and Goal Statement

This activity is intended for primary care physicians, cardiologists, nephrologists, nurses, nurse practitioners, physician assistants, pharmacists, and other clinicians who care for patients at risk for cardiovascular events.

The goal of this activity is for learners to be better able to evaluate the benefits vs risks for salt substitutes.

Upon completion of this activity, participants will:

  • Distinguish the outcomes of a previous large trial of a salt substitute
  • Evaluate the benefits vs risks for salt substitutes
  • Outline implications for the healthcare team


Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.

News Author

  • Megan Brooks

    Freelance writer, Medscape


    Megan Brooks has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.

Accreditation Statements


Interprofessional Continuing Education

In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.


This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; 0.25 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape, LLC designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number JA0007105-0000-22-370-H01-P).

    Contact This Provider

  • For Physician Assistants

    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 10/14/2023. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


Can Salt Substitutes Reduce Cardiovascular Diseases, Stroke, and Death?

Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 10/14/2022

Valid for credit through: 10/14/2023, 11:59 PM EST


Clinical Context

Replacing sodium chloride with potassium chloride has been demonstrated to have salutary effects on blood pressure, and these effects inspired Neal and colleagues to conduct a randomized trial of salt substitute featuring 75% sodium chloride and 25% potassium chloride vs traditional salt with 100% sodium chloride. The study involved 20,995 participants in more than 600 villages in rural China, and the results of this study were published in the September 16, 2021, issue of the New England Journal of Medicine.[1] Participants were at least 60 years of age and had a history of hypertension and stroke.

The salt substitute cohort experienced an odds ratio (OR) of 0.86 (95% confidence interval [CI], 0.77-0.96) for recurrent stroke, 0.87 (95% CI, 0.80-0.94) for cardiovascular events, and 0.88 (95% CI, 0.82-0.95) for mortality. Moreover, the salt substitute was not associated with higher rates of hyperkalemia compared with traditional salt.

This trial was one of the most important studies of salt substitute to date. The current meta-analysis provides a broad overview of the effects of salt substitutes on important outcomes.

Study Synopsis and Perspective

Dietary salt substitutes not only lower blood pressure but also have a clear effect on hard clinical endpoints, lowering the risk for myocardial infarction (MI), stroke, death from all causes, and cardiovascular disease (CVD), a meta-analysis shows.

The blood pressure–mediated protective effects of salt substitutes on CVD and death are likely to apply to the roughly 1.28 billion people around the world who have high blood pressure, the researchers say.

"These findings are unlikely to reflect the play of chance and support the adoption of salt substitutes in clinical practice and public health policy as a strategy to reduce dietary sodium intake, increase dietary potassium intake, lower blood pressure and prevent major cardiovascular events," they write.

The study was published online August 10 in Heart.[2]

Strong Support for Landmark Study

In salt substitutes, a proportion of sodium chloride is replaced with potassium chloride. Salt substitutes are known to help lower blood pressure, but less is known about their effect on hard clinical endpoints, Maoyi Tian, PhD, from Harbin Medical University, Harbin, China, and the George Institute for Global Health, Sydney, Australia, and colleagues note in their article.

In the landmark Salt Substitute and Stroke Study (SSaSS), salt substitutes cut the risk for MI, stroke, and early death, as reported previously by | Medscape Cardiology.[3]

But SSaSS was conducted in China, and it was unclear whether these benefits would apply to people in other parts of the world.

To investigate, Dr Tian and colleagues pooled data from 21 relevant parallel-group, step-wedge, or cluster randomized controlled trials published through August 2021, with 31,949 participants. The trials were conducted in Europe, the Western Pacific Region, the Americas, and South-East Asia and reported the effect of a salt substitute on blood pressure or clinical outcomes.

A meta-analysis of blood pressure data from 19 trials that included 29,528 participants showed that salt substitutes lowered systolic blood pressure (SBP) by 4.61 mm Hg (95% CI, −6.07 to −3.14) and diastolic blood pressure (DBP) by 1.61 mm Hg (95% CI, −2.42 to −0.79).

The proportion of sodium chloride in the salt substitutes varied from 33% to 75%; the proportion of potassium ranged from 25% to 65%.

Each 10% lower proportion of sodium chloride in the salt substitute was associated with a 1.53 mm Hg (95% CI, −3.02 to −0.03; P=.045) greater reduction in SBP and a 0.95 mm Hg (95% CI, −1.78 to −0.12; P=.025) greater reduction in DBP.

Reductions in blood pressure appeared consistent irrespective of country, age, sex, history of high blood pressure, weight, baseline blood pressure, and baseline levels of urinary sodium and potassium.

Clear Benefit on Hard Outcomes

Pooled data on clinical outcomes from 5 trials that included 24,306 participants, mostly from the SSaSS, and showed clear protective effects of salt substitutes on total mortality (risk ratio [RR], 0.89; 95% CI, 0.85-0.94), CV mortality (RR, 0.87; 95% CI, 0.81-0.94), and CV events (RR, 0.89; 95% CI, 0.85-0.94).

Dr Tian and colleagues write, "Broader population use of salt substitute is supported by the absence of any detectable adverse effect of salt substitutes on hyperkalaemia in this review."

They note, however, that all of the trials took "pragmatic steps to exclude participants at elevated risk of hyperkalaemia, seeking to exclude those with chronic kidney disease or using medications that elevate serum potassium."

Offering perspective on the study, Harlan Krumholz, MD, from Yale New Haven Hospital and Yale School of Medicine, New Haven, Connecticut, said it provides "useful information by bringing together the trial evidence on salt substitutes. The evidence is dominated by the SSaSS, but the others add context."

Dr Krumholz said that at this point, he thinks salt substitutes "could be included in recommendations to patients.

"SSaSS was conducted in villages in China, so that is where the evidence is strongest and most relevant, but this is a low-cost and seemingly safe strategy that could be tried by anyone without contraindications, such as kidney disease or taking a potassium-sparing medication or potassium supplement," Dr Krumholz told | Medscape Cardiology.

Johanna Contreras, MD, heart failure and transplant cardiologist at the Mount Sinai Hospital in New York, agrees that in the absence of contraindications, salt substitutes should be recommended.

"Americans put salt on everything and don't even think about it. The salt substitutes are very helpful," Dr Contreras told | Medscape Cardiology.

"People who don't have high blood pressure should limit salt intake because what we have seen is that if you have high blood pressure in your family--even if you don't have high blood pressure in your 20s or 30s--you're likely to develop high blood pressure," Dr Contreras said.

"Therefore, it's wise early on to start protecting yourself and using low salt and salt substitutes," she added.

The study had no specific funding. Dr Tian, Dr Krumholz, and Dr Contreras have disclosed no relevant financial relationships.

Heart. Published online August 10, 2022.

Study Highlights

  • Researchers searched for randomized controlled trials of salt substitute, which was defined by the replacement of at least 5% of sodium chloride with potassium chloride.
  • Outcomes of interest included blood pressure, cardiovascular events, and mortality.
  • Researchers assessed outcomes based on patient subgroups defined by age, a history of hypertension, and other variables.
  • Of 86 studies that qualified for full-text review, 21 were included in the meta-analysis. The studies were diverse in terms of geography, although there were no trials conducted in Africa.
  • The mean baseline SBP among participants varied between 113 and 177 mm Hg, and the mean DBP values ran from 71 to 105 mm Hg.
  • 11 studies were judged to be at a low risk for bias, and 2 were at high risk.
  • The mean reduction in the salt substitute vs control group in SBP was −4.61 mm Hg (95% CI, −6.07 to −3.14 mm Hg), and the respective mean reduction in DBP was −1.61 mm Hg (95% CI, −2.42 to −0.79 mm Hg).
  • Trials of less than 12 months' duration demonstrated more powerful reductions in blood pressure associated with salt substitutes.
  • For each 10% reduction in sodium chloride content in the salt substitute, the mean reduction in SBP was −1.53 mm Hg.
  • The positive effects of salt substitutes on blood pressure were unchanged in subgroup analyses based on age, sex, geographical area, history of hypertension, body mass index, baseline blood pressure, and baseline 24-hour urinary excretion.
  • Five studies reported on all-cause mortality, and 2 reported on cardiovascular events. The large study by Neal and colleagues accounted for more than 87% of these outcomes among included research.
  • The pooled RR for all-cause mortality in the salt substitute vs control groups was 0.89 (95% CI, 0.85-0.94), and the respective RR for cardiovascular mortality was 0.87 (95% CI, 0.81-0.94). The RR for cardiovascular events in comparing the salt substitute and control groups was 0.89 (95% CI, 0.85-0.94).
  • Salt substitute was associated with a mean reduction in 24-hour urine sodium of −0.48 g/day and a mean increase in urinary potassium excretion of 0.45 g/day.
  • Two studies demonstrated no increase in the risk for hyperkalemia with salt substitute vs placebo.

Clinical Implications

  • This previous randomized controlled trial demonstrated that a salt substitute cohort was associated with a reduction in the risks for stroke, cardiovascular events, and mortality of 12% to 14%. Moreover, the salt substitute was not associated with higher rates of hyperkalemia compared with traditional salt.
  • In the current meta-analysis, salt substitute was associated with reductions in SBP and DBP in all subgroups studied. Based largely on the results of 1 trial in a high-risk population, salt substitute was associated with lower risks for cardiovascular events and all-cause mortality.
  • Implications for the healthcare team: The healthcare team should advocate for the use of salt substitute among patients at elevated risk for cardiovascular events.


Earn Credit

  • Print