CLINICAL QUESTION: Does advising liberal fluid intake, compared to fluid restriction, improve health status without compromising safety in stable chronic heart failure (CHF)?
BACKGROUND: Fluid restriction is frequently advised in patients with heart failure, on the assumption that it may prevent fluid overload, though data supporting its benefit are limited.
STUDY DESIGN: Multicenter, randomized, open-label, clinical trial
SETTING: Seven sites in the Netherlands
SYNOPSIS: 504 patients with stable CHF in an outpatient setting were randomly assigned to liberal fluid intake or fluid restriction (up to 1,500 ml per day). The primary outcome studied was health status after three months, as assessed by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS). There was no significant difference in scores between the liberal fluid intake group (mean score, 74) and the fluid restriction group (mean score, 72.2), with a mean difference after adjustment for baseline scores of 2.17 (95% CI, 0.06 to 4.39; P = 0.06).
The key secondary outcome was thirst distress as assessed by the Thirst Distress Scale for HF (TDS-HF), which was significantly lower in the liberal fluid intake group (TDS-HF: 16.9 versus 18.6, with a mean difference of 2.29 (95% CI, −1.09 to −3.49; P <0.001)). No significant differences were observed in the composite of death, HF, and all-cause hospitalizations, and IV loop diuretic use during the total six months of clinical follow-up. No significant difference was observed in NT-proBNP values or weight.
BOTTOM LINE: In stable CHF patients, liberal fluid intake advice appears safe and improves thirst distress without worsening health status compared to a restrictive fluid approach.
CITATION: Herrmann JJ, et al. Liberal fluid intake versus fluid restriction in chronic heart failure: a randomized clinical trial. Nat Med. 2025;31(6):2062-2068. doi: 10.1038/s41591-025-03628-4.
Dr. Salem
Dr. Abou Assalie
Drs. Salem and Dr. Abou Assalie are hospitalists at The Ohio State University Wexner Medical Center in Columbus, Ohio.