419 - Salt Substitute, Preeclampsia Prevention, Emotional Well-being
Take 3 – Practical Practice Pointers©
From the Literature
1) Salt Substitutes to Improve CV Outcomes on a Grand Scale
The 2017 ACC/AHA guidelines for the management of hypertension emphasize reducing salt and supplementing potassium for patients as part of non-pharmacologic therapy. The authors of a recently published study “went big” and “went home” with this idea. The researchers from Peking University and the University of Sydney (Australia) randomized 600 villages (20,995 subjects) in rural China to a salt substitute (75% sodium chloride, 25% potassium chloride) vs. usual salt (typical 100% sodium) and studied stroke, major cardiovascular events, death and hyperkalemia.
The recruitment and consenting process of the villages was described as voluntary - the leadership councils and the health departments of the villages agreed to participate. Individual subjects (and their households) were enrolled within those villages if they were 60 years old or older, had elevated blood pressure, ate most of their meals at home, and neither they nor anyone in the house had a contraindication to potassium supplementation (such as renal disease or use of a potassium-sparing diuretic). The household was given the salt substitute for free and instructed to use that for all their dietary salt uses but were told to use this salt more sparingly than their usual salt. There was also general health advice given to both intervention and control villages about stroke prevention, including reducing salt intake.
Most of the participants (79%) were on anti-hypertensives already, their mean blood pressure was 154/89 and a surprising (to me) 72% of subjects had already had a stroke. The salt substitute reduced stroke (by 4.5 events per 1000 person-years, which translates very roughly to an NNT of 50 over 5 years). Major adverse cardiovascular events (“nonfatal stroke, nonfatal acute coronary syndrome, or death from vascular causes”) were reduced by 7.2 per 1000 person-years and overall mortality was reduced by 5.3 per 1000 person-years. There were no differences in the rates of hyperkalemic events between groups.
While sodium reduction and potassium supplementation have been shown to reduce hypertension and have been part of hypertension management guidelines for years, this trial serves as a reminder of the power of a public/population health intervention to prevent disease on a large scale. In my opinion, the recent changes in the ACC/AHA guidelines extending the role of pharmacologic therapy to lower blood pressures thresholds has the adverse effect of de-emphasizing the diet and exercise changes that can help control blood pressure. I acknowledge, however, that prescribing a pill is easier than helping someone change their lifestyle – which is why population-level efforts like this might be a better solution.
- Neal B, Wu Y, Feng X, Zhang R, Zhang Y, Shi J, et al. Effect of Salt Substitution on CV Events and Death. N Engl J Med. 2021 Sep 16;385(12):1067–77. Link
From the US Preventive Services Task Force (USPSTF)
2) Aspirin Use to Prevent Preeclampsia
Preeclampsia is one of the most serious health problems that affect pregnant women. It is a complication in approximately 4% of pregnancies in the US and contributes to both maternal and infant morbidity and mortality. It also accounts for 6% of preterm births and 19% of medically indicated preterm births. There are racial and ethnic disparities in the prevalence of and mortality from preeclampsia. Non-Hispanic Black women are at greater risk for developing preeclampsia than other women and experience higher rates of maternal and infant morbidity and perinatal mortality. There are certain conditions that place women at higher risk for preeclampsia, and research has shown that taking low-dose aspirin starting in the 2nd trimester can help prevent preeclampsia in these higher risk populations.
The USPSTF recently updated their 2014 recommendation regarding aspirin therapy to prevent preeclampsia and related complications. The updated recommendation is for the use of low-dose aspirin (81mg/d) as preventive medication for preeclampsia after 12 weeks gestation in women who are at high risk. (B recommendation). They concluded with moderate certainty that there is a substantial net benefit of daily low-dose aspirin use to reduce the risk for preeclampsia as well as preterm birth, SGA/IUGR, and perinatal mortality in persons at high risk for preeclampsia.
High risk factors include:
- History of preeclampsia, especially when accompanied by an adverse outcome
- Multifetal gestation
- Chronic hypertension
- Pregestational type 1 or 2 diabetes
- Kidney disease
- Autoimmune disease (ie, systemic lupus erythematous, antiphospholipid syndrome)
- Combinations of > 2 moderate-risk factors.
- Moderate risk factors include nulliparity, obesity (body mass index >30), family history of preeclampsia (ie, mother or sister), black persons (due to social, rather than biological, factors), lower income, age > 35, personal history factors (eg, low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval), and in vitro conception. (see the table at the 2nd reference for additional details)
The recommendation also notes that consideration should be given to start low-dose aspirin if the patient has 1 of the moderate-risk factors.
This recommendation is in line with the 2018 recommendation from the American College of Obstetrics and Gynecology (ACOG) which states that low-dose aspirin (81 mg/d) should be used for prophylaxis for women at high risk of preeclampsia starting between 12 and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery.
While the majority of primary care clinicians do not include pre-natal or obstetrical care as part of their medical practice, most provide healthcare for women during their childbearing years. As such, it is important to be aware of this recommendation and be an educational resource since we may be the first to care for them when they become pregnant and will often be caring for them during pregnancy for other medical concerns.
From the PeerRxMed (www.PeerRxMed.org) Blog
3) Consume More “Healthy Facts” for Emotional Well-being
“The brain is like Velcro for negative experiences, but Teflon for positive ones.” Rick Hanson, PhD
It happens again … and again. One small glitch while using our electronic health record (EHR) can quickly send my emotions spinning out of control and have me experiencing “potty brain” and sometimes even “potty mouth.” I suspect some of you can relate. Or perhaps you’re derailed by a negative patient interaction, these days often having something to do with COVID? Yeah, those get me as well.
I’m left wondering why I have such strong and predictably negative reactions under particular circumstances? The explanation, according to neuroscience research, is that our brain has a pre-programmed “negativity bias” that evolved over millions of years as a survival mechanism. Once we have labeled something as negative, we have an implicit memory that is made up of our previously imprinted emotions and unless we do something different, we will likely continue to get more of the same.
As I have experienced just how powerful this negativity bias is in my own life and watched it play out in the lives of colleagues, I have started to consider how I can better discipline myself to emotionally consume more of the “good facts” and avoid the “bad facts.” After all, despite the frustrations I experience with our EHR, for example, I’d never want to go back to paper charts (for those who can even remember such a thing!). And when I’m honest with myself, some of my more “challenging patients” have also become some of my favorites. So this reframing of my “emotional diet” is not about denial, but rather about perspective. By knowing my pre-programmed tendency to reach for those “bad facts,” particularly in certain circumstances, I can be more conscious about choosing a more balanced emotional diet.
Psychologist Rick Hanson recommends 3 steps to help with this process. First, he suggests that we be on the lookout for the good facts of positive events and turn them into good experiences by consciously noticing and allowing good feelings as they are happening. Second, we should hold those positive emotions in awareness for 20-30 seconds and really enjoy the experience. By staying with your positive feelings and allowing them to “fill you up,” you are reinforcing positive synaptic connections in your brain. Finally, we should intend and visualize our future consumption of these “good facts” that are indeed all around so over time we can build stronger positive connections.
Breaking the habit of our often-mindless consumption of “negative facts” seems like a wise investment for a healthier emotional future. This week consider how you might look for opportunities to “consume” more positive experiences. I suspect you’ll experience a lot less emotional heartburn ….
Mark and John
Carilion Clinic Department of Family and Community Medicine
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