• Andrew Mente, Martin J O'Donnell, Sumathy Rangarajan, Matthew J McQueen, Paul Poirier, Andreas Wielgosz, Howard Morrison, Wei Li, Xingyu Wang, Chen Di, Prem Mony, Anitha Devanath, Annika Rosengren, Aytekin Oguz, Katarzyna Zatonska, Afzal Hussein Yusufali, Patricio Lopez-Jaramillo, Alvaro Avezum, Noorhassim Ismail, Fernando Lanas, Thandi Puoane, Rafael Diaz, Roya Kelishadi, Romaina Iqbal, Rita Yusuf, Jephat Chifamba, Rasha Khatib, Koon Teo, Salim Yusuf, and PURE Investigators.
• The authors' affiliations are listed in the Appendix.
• N. Engl. J. Med.. 2014 Aug 14;371(7):601-11.

BackgroundHigher levels of sodium intake are reported to be associated with higher blood pressure. Whether this relationship varies according to levels of sodium or potassium intake and in different populations is unknown.MethodsWe studied 102,216 adults from 18 countries. Estimates of 24-hour sodium and potassium excretion were made from a single fasting morning urine specimen and were used as surrogates for intake. We assessed the relationship between electrolyte excretion and blood pressure, as measured with an automated device.ResultsRegression analyses showed increments of 2.11 mm Hg in systolic blood pressure and 0.78 mm Hg in diastolic blood pressure for each 1-g increment in estimated sodium excretion. The slope of this association was steeper with higher sodium intake (an increment of 2.58 mm Hg in systolic blood pressure per gram for sodium excretion >5 g per day, 1.74 mm Hg per gram for 3 to 5 g per day, and 0.74 mm Hg per gram for <3 g per day; P<0.001 for interaction). The slope of association was steeper for persons with hypertension (2.49 mm Hg per gram) than for those without hypertension (1.30 mm Hg per gram, P<0.001 for interaction) and was steeper with increased age (2.97 mm Hg per gram at >55 years of age, 2.43 mm Hg per gram at 45 to 55 years of age, and 1.96 mm Hg per gram at <45 years of age; P<0.001 for interaction). Potassium excretion was inversely associated with systolic blood pressure, with a steeper slope of association for persons with hypertension than for those without it (P<0.001) and a steeper slope with increased age (P<0.001).ConclusionsIn this study, the association of estimated intake of sodium and potassium, as determined from measurements of excretion of these cations, with blood pressure was nonlinear and was most pronounced in persons consuming high-sodium diets, persons with hypertension, and older persons. (Funded by the Heart and Stroke Foundation of Ontario and others.).

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