Liberal Versus Restricted Fluid Administration in Heart Failure Patients

Abstract

SummaryRestrictive fluid intake is recommended, in addition to standard pharmacologic treatment, in the treatment of patients with chronic heart failure (CHF). However, this recommendation lacks firm scientific evidence. We conducted a systematic review and meta-analysis of published randomized controlled trials to estimate the effect of fluid restriction in patients with heart failure.Randomized controlled trials were identified in the MEDLINE, EMBASE, and Cochrane databases using the search-keywords "fluid" and "heart failure". Outcomes were compared in heart failure patients with liberal and restricted fluid intake. Pooled risk ratios (RR) and weighted mean differences (WMD) were calculated using random effects models. Studies focusing on decompensated heart failure were analyzed separately.Six small randomized trials comparing liberal and restricted fluid intake met the inclusion criteria. Significant heterogeneity was noted in the reported studies for several outcomes. There were no differences in readmission rate (5 studies, pooled RR = 1.32; 95% CI: 0.86 to 2.01; P = 0.2), mortality rate (5 studies, pooled RR = 1.50; 95% CI: 0.87 to 2.57; P = 0.14), perceived thirst (4 studies, WMD = -0.7; 95% CI: -2.58 to 1.17; P = 0.46), duration of intravenous diuretics (2 studies, WMD = 0.17; 95% CI: -1.26 to 1.6; P = 0.81) or serum sodium levels (WMD = -1.61; 95% CI: -3.28 to 0.07; P = 0.06) between the liberal fluid intake group and the restrictive fluid intake group. Mean serum creatinine and BNP levels were significantly higher in the liberal fluid group: WMD 0.20 (95% CI: 0.15 to 0.25; P < 0.00001) and 172.59 (95% CI: 67.38 to 277.8; P = 0.001), respectively. There was no difference in any of the outcomes after correcting for heterogeneity.While studies to date are limited by heterogeneity and small sample sizes, the combined data suggest similar clinical outcomes in patients with CHF managed with liberal and restrictive fluid intake. Larger studies are needed to confirm our findings. (Int Heart J 2015; 56: 192-195) Key words: Fluid-resriction, Heart dysfunction, Water-intake I n addition to standard pharmacologic treatment, restrictive fluid intake is often used in the treatment of patients with heart failure. 1,2) While international professional guidelines have recommended fluid restriction for patients with chronic heart failure (CHF), this recommendation lacks firm scientific evidence. This strategy can be stressful to patients and should be supported by better evidence of improved outcomes if it is to be widely used.Prior studies comparing liberal to restricted fluid intake in heart failure patients are limited by small sample sizes, and their individual results do not permit firm conclusions to be drawn. In fact, recent studies have questioned the benefit of fluid restriction in heart failure patients.3,4) To synthesize and provide the best possible evidence for application in clinical practice, we conducted a systematic review and meta-analysis of published randomized controlled trials to estimate the ...

Effects of limiting fluid intake on clinical and laboratory outcomes in patients with heart failure

“…The appropriateness and efficacy of fluid restriction in the diet for better management of heart failure was the main subject of the present meta-analysis, either in the presence of acute ADHF [4,9] or within a setting of chronic heart failure, pharmacologically compensated [5][6][7][8]. The rationale of the water restriction in the management of heart failure has been questioned by several authors [5,10,12]. A first concern consists of the fact that in heart failure patients it seems that limitation of water intake is associated with very troublesome thirst, which further impairs the quality of life of these patients [13][14][15].…”

“…Moreover, when carefully weighing the pros and cons of limiting patients' water supply, even coronary hypoperfusion, by the decrease of effective circulating volume, should be taken into account. In fact, worsening renal function and cardiac ischemia, elicited by hypoperfusion, can concur to aggravate heart failure [12].…”

The use of diuretics in heart failure with congestion — a position statement from the Heart Failure Association of the European Society of Cardiology

“…Currently four trials are evaluating the benefit of sodium restriction, including one trial assessing a hard clinical endpoint . A meta‐analysis on fluid restriction did not indicate benefit or harm when performed in heart failure patients . Therefore, dietary restrictions should be adapted according to the clinical context.…”

Restriction therapy in acute heart failure is not shown to be effective

“…6 While it did not specifically address clinical outcomes in decompensated patients such as ours, we did investigate the studies they collected and analyzed. We found no additional studies investigating clinical outcomes in patients with decompensated heart failure.…”