Do patients with heart failure with preserved ejection fraction (HFpEF) need to limit their oral fluid intake?

Fluid Restriction in Heart Failure with Preserved Ejection Fraction

Routine fluid restriction is not recommended for all patients with heart failure with preserved ejection fraction (HFpEF) as there is insufficient evidence to support this practice for improving clinical outcomes. 1

Current Evidence on Fluid Restriction in HFpEF

• The 2022 AHA/ACC/HFSA guideline for heart failure management specifically states that "the benefit of fluid restriction to reduce congestive symptoms is uncertain" in patients with advanced heart failure and hyponatremia (Class 2b, Level of Evidence C-LD) 1

• Fluid restriction has traditionally been considered a cornerstone of heart failure self-care management, but recent evidence questions its universal application, particularly in HFpEF patients 2

• Studies evaluating stringent fluid restriction compared to liberal fluid intake have not demonstrated significant benefits regarding clinical stability or body weight in heart failure patients 2

Appropriate Fluid Management in HFpEF

When Fluid Restriction May Be Considered

• Temporary fluid restriction can be considered in specific clinical scenarios:

  • Patients with decompensated heart failure 2
  • Patients with hyponatremia (serum sodium <134 mEq/L) 1, 2

• When fluid restriction is implemented, a tailored approach based on body weight (approximately 30 ml/kg per day) appears most reasonable rather than arbitrary fixed limits 2

Management of Fluid Status in HFpEF

• Diuretic therapy remains the mainstay for managing fluid overload symptoms in HFpEF patients 3

• Monitoring for fluid overload is critical as HFpEF patients with measurable fluid overload face worse prognosis compared to euvolemic patients 4

• The 2013 ACCF/AHA guidelines recommend:

  • Careful measurement of fluid intake and output 1
  • Daily weight monitoring at the same time each day 1
  • Assessment of clinical signs and symptoms of systemic perfusion and congestion 1

Evidence-Based Approach to HFpEF Management

• The treatment of HFpEF should focus on three key strategies:

  • Treating precipitating conditions (e.g., hypertension, atrial fibrillation) 3
  • Controlling symptoms by maintaining euvolemia with appropriate diuretic therapy 3
  • Avoiding therapies that have not shown benefit unless other compelling indications exist 3

• Sodium restriction (rather than fluid restriction) may be reasonable for patients with symptomatic heart failure to reduce congestive symptoms (Class IIa, Level of Evidence C) 1

Practical Recommendations

• Instead of universal fluid restriction, focus on:

  • Appropriate diuretic therapy to maintain euvolemia 3
  • Sodium restriction for symptom management 1
  • Regular monitoring of weight and symptoms 1
  • Education on recognizing signs of fluid overload 1

• For patients requiring temporary fluid restriction due to decompensation or hyponatremia:

  • Provide clear education and support to increase adherence 2
  • Implement planned evaluations to assess effectiveness 2
  • Consider tailoring restriction based on body weight rather than using arbitrary limits 2

Conclusion

The management of fluid status in HFpEF should focus on appropriate diuretic therapy and sodium restriction rather than universal fluid restriction. Temporary fluid restriction should be reserved for specific situations such as decompensated heart failure or hyponatremia, with an individualized approach based on the patient's body weight and clinical status.