Clinical question: Does a restrictive fluid strategy improve clinical outcomes in heart failure (HF) patients compared to liberal fluid intake?
Background: Fluid restriction is often recommended for patients with HF; however, current guidelines recommend it only for certain patients, and there is limited high-quality evidence. Previous meta-analyses found no difference between restricted and liberal fluid groups but were limited by small sample sizes and inconsistent methods. The recent FRESH-UP study provided new data and enabled an updated systematic review and meta-analysis to examine fluid restriction in heart failure.
Study design: Systematic review and meta-analysis of four randomized controlled trials comparing restrictive versus liberal fluid intake in HF patients
Setting: HF outpatients from multiple hospitals located in Ireland, Sweden, the Netherlands, and the U.S.
Synopsis: This meta-analysis showed no significant differences in all-cause mortality, HF rehospitalization, or thirst between restrictive and liberal fluid groups. Quality-of-life questionnaires also showed no significant differences between the two groups. There was a nonsignificant trend towards increased acute kidney injury (AKI) in the fluid-restricted group. The fluid-restricted group had significantly lower fluid intake than the liberal fluid group, but this did not translate into significant differences in outcomes. Notably, sodium restriction was among the study exclusion criteria; therefore, it was not evaluated in this study.
Bottom line: Despite lowering overall fluid intake, a restrictive fluid strategy has not been associated with any difference in mortality, readmission, thirst, or quality of life scores compared to a liberal fluid intake in heart failure patients.
Citation: Adamu UG, et al. Optimal fluid management strategies in patients with heart failure: a systematic review and meta-analysis of randomized controlled trials. Front Cardiovasc Med. 2025.doi:10.3389/fcvm.2025.1636862.
Dr. Krach is a hospitalist in the department of hospital medicine at the Cleveland Clinic and a clinical assistant professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, both in Cleveland.