What is the recommended fluid intake for patients with Heart Failure with reduced Ejection Fraction (HFrEF)?

Fluid Intake Recommendations for Patients with Heart Failure with Reduced Ejection Fraction (HFrEF)

For patients with HFrEF, fluid restriction of 1.5-2 L/day should only be considered in those with severe heart failure to relieve symptoms and congestion, while routine fluid restriction is not recommended for patients with mild to moderate symptoms. 1

General Fluid Intake Guidelines

• Fluid restriction is not recommended as a routine intervention for all HFrEF patients 1, 2
• For patients with mild to moderate symptoms (NYHA class I-II), there is no benefit to routine fluid restriction 1, 3
• For patients with severe symptoms (NYHA class III-IV), fluid restriction of 1.5-2 L/day may be considered to relieve symptoms and congestion 1, 2
• Weight-based fluid restriction (30 mL/kg body weight, or 35 mL/kg if body weight >85 kg) is more reasonable than fixed restrictions and may cause less thirst 1, 3

Specific Clinical Scenarios

For Patients with Hyponatremia:

• Restriction of hypotonic fluids to 1.5-2 L/day may improve hyponatremia 1, 2
• Regular monitoring of serum sodium levels is necessary to assess effectiveness 2

For Patients with Fluid Overload/Congestion:

• Patients should monitor and record daily weight to recognize rapid weight gain 1
• A sudden unexpected weight gain of >2 kg in 3 days should trigger an increase in diuretic dose and/or alert the healthcare team 1
• Low-dose loop and thiazide diuretics should be considered for symptomatic patients to improve heart failure symptoms 1

For Patients Traveling:

• When traveling to hot climates, an additional intake of 0.5-1.0 L per day of non-alcoholic drinks is recommended 1
• Patients should regularly check their body weight during travel and adjust diuretic doses and fluid intake accordingly 1

Patient Education and Self-Care

• Patients should be educated on how to monitor and recognize signs and symptoms of fluid overload 1
• Patients should understand when and how to notify healthcare providers about changes in symptoms or weight 1
• Patients should be taught how to use flexible diuretic therapy if appropriate and recommended 1

Evidence Quality and Controversies

• The evidence for fluid restriction in HFrEF is generally of low quality 2, 4
• Recent data challenges the beneficial role of strict fluid restriction in heart failure 5
• Some studies suggest that a more liberal fluid intake in clinically stabilized HFrEF patients may decrease thirst without negative effects on symptoms or physical capacity 6
• One meta-analysis found that fluid restriction alone might reduce mortality and hospitalization (low quality evidence), while sodium restriction alone might increase these risks 4

Common Pitfalls and Caveats

• Overly aggressive fluid restriction may lead to increased thirst and reduced quality of life 2, 6
• Fluid restriction may increase risk of heat stroke in hot or low-humidity climates, particularly in advanced heart failure 2
• Fluid restriction should not be implemented in isolation but as part of comprehensive heart failure management 2
• Adherence to fluid restriction can be challenging for patients and requires proper education and support 3, 7