Restricting fluid in HF may not be necessary after all

The outcomes of the FRESH-UP study questioned the assumed benefit of a fluid restriction regimen in patients with chronic heart failure (HF). The study did not reveal an advantage in disease outcomes for participants on a fluid restriction regimen compared with those not on a fluid restriction regimen, while the latter did suffer from thirst distress.

“Although restricting fluid is a common recommendation for patients with HF, evidence in this area is of low quality,” outlined Dr Roland van Kimmenade (Radboud University Medical Center, the Netherlands) [1]. That was the rationale for the FRESH-UP study (NCT04551729), which compared fluid restriction with liberal fluid intake in patients with chronic HF. Participants (n=504) were randomised 1:1 to fluid restriction, which comprised an advised maximum intake of 1,500 mL per day, or liberal fluid intake. The primary outcome was the health status at 3 months, as measured by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS).

In the liberal fluid intake arm, the mean KCCQ-OSS score increased from 73.4 points at baseline to 74.0 points at 3 months. In the fluid restriction arm, there was a slight decline in this score from baseline (74.0) to 3 months (72.2 points). The adjusted mean difference between the study arms was 2.17 points, a non-significant difference (95% CI 0.06–4.39; P=0.06). Other health outcomes, such as death, all-cause hospitalisation, hospitalisation for HF, and acute kidney injury, did not display differences between the treatment groups either (see Table). However, participants in the fluid restriction group had significantly more thirst distress, as was assessed by the thirst distress scale in HF (16.9 vs 18.6; P<0.001).

Table: Secondary outcomes in FRESH-UP [1]



3M, 3 months; HF, heart failure.

“We did see a numerical benefit in KCCQ-OSS for patients in the fluid restriction arm, but this was not a significant difference,” Dr van Kimmenade summarised. “We did not see any differences between the 2 groups with respect to other health outcomes either, which makes us doubt the value of fluid restriction in patients with chronic HF.”

1. Van Kimmenade RRJ, et al. Liberal fluid intake versus fluid restriction in chronic heart failure: the FRESH-UP study. Late-breaking Clinical Trials IV, ACC 2025 Scientific Session, 29–31 March, Chicago, USA.

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Posted on 22 May 202522 May 2025