Skip to content

Neal B, et al. Effect of Salt Substitution on Cardiovascular Events and Death. N Engl J Med. 2021;385:1067–1077. PMID 34459569

One-paragraph summary

SSaSS randomized 600 rural Chinese villages and 20,995 high-risk adults to use a salt substitute containing 75% sodium chloride and 25% potassium chloride or continue usual salt. Over a mean 4.74 years, salt substitution reduced stroke, major cardiovascular events, and death. Stroke rate ratio was 0.86 (95% CI 0.77–0.96), major cardiovascular events 0.87 (0.80–0.94), and death 0.88 (0.82–0.95). Serious hyperkalemia events were not significantly increased, RR 1.04 (0.80–1.37), but ascertainment and transfer to CKD-rich populations require care.

Design

Element Detail
Unit randomized 600 villages
Participants 20,995 people with prior stroke or age ≥60 plus uncontrolled BP
Intervention 75% NaCl / 25% KCl salt substitute
Comparator Usual salt
Mean follow-up 4.74 years
Primary outcome Stroke

Key findings

  • Stroke: rate ratio 0.86 (95% CI 0.77–0.96).
  • Major cardiovascular events: 0.87 (95% CI 0.80–0.94).
  • Death: 0.88 (95% CI 0.82–0.95).
  • Serious hyperkalemia: 1.04 (95% CI 0.80–1.37).
  • The intervention changed a default food input rather than depending only on counseling.

Limitations

  • Most discretionary sodium came from household salt; effects may differ where processed food dominates.
  • The population was rural, older, and high-risk; generalizability is not automatic.
  • Serious hyperkalemia ascertainment may miss biochemical events.
  • Potassium-enriched salt is inappropriate for some people with impaired potassium excretion or interacting medicines.
  • HHD imaging was not measured, so cardiac remodeling benefit is inferred through BP and event reduction.

Why it matters

SSaSS shows that prevention can be designed into the food environment and can change hard outcomes. It also makes the safety boundary explicit: scalable sodium reduction and potassium substitution require procurement, labeling, kidney-risk screening, and context-specific surveillance.

Cited by wiki pages

  • lifestyle and population prevention
  • patient experience and advocacy