Urinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE): A Case

Urinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE): A Case–Control Study

Published:2020-11-16 Issue:4 Volume:34 Page:414-425
ISSN:0895-7061
Container-title:American Journal of Hypertension
language:en
Short-container-title:

Author:

Judge Conor¹²³^ORCID,O’Donnell Martin J¹²,Hankey Graeme J⁴,Rangarajan Sumathy²^ORCID,Chin Siu Lim²,Rao-Melacini Purnima²,Ferguson John¹,Smyth Andrew¹,Xavier Denis⁵,Lisheng Liu⁶,Zhang Hongye⁷,Lopez-Jaramillo Patricio⁸^ORCID,Damasceno Albertino⁹^ORCID,Langhorne Peter¹⁰,Rosengren Annika¹¹,Dans Antonio L¹²,Elsayed Ahmed¹³,Avezum Alvaro¹⁴,Mondo Charles¹⁵,Ryglewicz Danuta¹⁶,Czlonkowska Anna¹⁷,Pogosova Nana¹⁸,Weimar Christian¹⁹,Diaz Rafael²⁰,Yusoff Khalid²¹,Yusufali Afzalhussein²²^ORCID,Oguz Aytekin²³,Wang Xingyu⁷,Lanas Fernando²⁴^ORCID,Ogah Okechukwu S²⁵,Ogunniyi Adesola²⁶,Iversen Helle K²⁷,Malaga German²⁸,Rumboldt Zvonko²⁹,Oveisgharan Shahram³⁰,Al Hussain Fawaz³¹,Yusuf Salim²

Affiliation:

1. Department of Medicine, NUI Galway, Galway, Ireland

2. Department of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada

3. Wellcome Trust Health Research Board Irish Clinical Academic Training (ICAT), Dublin, Ireland

4. School of Medicine and Pharmacology, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia

5. Department of Medicine, St John’s Medical College and Research Institute, Bangalore, India

6. Department of Medicine, National Center of Cardiovascular Disease, Beijing, China

7. Department of Medicine, Beijing Hypertension League Institute, Beijing, China

8. Department of Medicine, Instituto de Investigaciones MASIRA, Universidad de Santander, Bucaramanga, Colombia

9. Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique

10. Department of Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland, UK

11. Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden

12. College of Medicine, University of Philippines, Manila, Philippines

13. Department of Surgery, Al Shaab Teaching Hospital, Khartoum, Sudan

14. Department of Medicine, International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil

15. Department of Medicine, Kiruddu National Referral Hospital, Kampala, Uganda

16. Military Institute of Aviation Medicine, Warsaw, Poland

17. Department of Medicine, Military Institute of Aviation Medicine, Warsaw, Poland

18. Department of Medicine, National Medical Research Center of Cardiology, Moscow, Russia

19. Department of Neurology, University Hospital, Essen, Germany

20. Department of Medicine, Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina

21. Department of Medicine, Universiti Teknologi MARA, Selayang, Selangor and UCSI University, Kuala Lumpur, Malaysia

22. Department of Medicine, Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, UAE

23. Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Turkey

24. Faculty of Medicine, Universidad de La Frontera, Temuco, Chile

25. Department of Medicine, University College Hospital, Ibadan, Nigeria

26. Department of Medicine, University College Hospital, Ibadan, Oyo State, Nigeria

27. Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark

28. School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru

29. Department of Medicine, University of Split, Split, Croatia

30. Department of Medicine, Rush Alzheimer Disease Research Center in Chicago, Chicago, Illinois, USA

31. Department of Medicine, King Saud University, Riyadh, Saudi Arabia

Abstract

Abstract BACKGROUND Although low sodium intake (<2 g/day) and high potassium intake (>3.5 g/day) are proposed as public health interventions to reduce stroke risk, there is uncertainty about the benefit and feasibility of this combined recommendation on prevention of stroke. METHODS We obtained random urine samples from 9,275 cases of acute first stroke and 9,726 matched controls from 27 countries and estimated the 24-hour sodium and potassium excretion, a surrogate for intake, using the Tanaka formula. Using multivariable conditional logistic regression, we determined the associations of estimated 24-hour urinary sodium and potassium excretion with stroke and its subtypes. RESULTS Compared with an estimated urinary sodium excretion of 2.8–3.5 g/day (reference), higher (>4.26 g/day) (odds ratio [OR] 1.81; 95% confidence interval [CI], 1.65–2.00) and lower (<2.8 g/day) sodium excretion (OR 1.39; 95% CI, 1.26–1.53) were significantly associated with increased risk of stroke. The stroke risk associated with the highest quartile of sodium intake (sodium excretion >4.26 g/day) was significantly greater (P < 0.001) for intracerebral hemorrhage (ICH) (OR 2.38; 95% CI, 1.93–2.92) than for ischemic stroke (OR 1.67; 95% CI, 1.50–1.87). Urinary potassium was inversely and linearly associated with risk of stroke, and stronger for ischemic stroke than ICH (P = 0.026). In an analysis of combined sodium and potassium excretion, the combination of high potassium intake (>1.58 g/day) and moderate sodium intake (2.8–3.5 g/day) was associated with the lowest risk of stroke. CONCLUSIONS The association of sodium intake and stroke is J-shaped, with high sodium intake a stronger risk factor for ICH than ischemic stroke. Our data suggest that moderate sodium intake—rather than low sodium intake—combined with high potassium intake may be associated with the lowest risk of stroke and expected to be a more feasible combined dietary target.

Funder

Canadian Institutes of Health Research

Heart and Stroke Foundation of Canada

Canadian Stroke Network

Swedish Research Council

Swedish Heart and Lung Foundation

The Health & Medical Care Committee of the Regional Executive Board

Region Västra Götaland

Wellcome Trust—Health Research Board Irish Clinical Academic Training

European Research Council COSIP

Publisher

Oxford University Press (OUP)