Journal of the American College of Cardiology (JACC)FRESH-UP: No Benefit in Limiting Fluid Intake in Patients With HF

The FRESH-UP trial represents a significant randomized controlled study examining the long-held practice of fluid restriction in heart failure patients. This multicenter Dutch study (n=504) directly compared restricted (1,500 mL/day) versus liberal fluid intake in primarily NYHA class II heart failure patients, measuring outcomes via validated KCCQ scores and clinical endpoints.

⚕️Key Clinical Considerations⚕️

• The primary finding showed no significant difference in health status (KCCQ-OSS scores: 74.0 liberal vs. 72.2 restricted) between fluid restriction and liberal intake groups at three months.
• Study population consisted predominantly of stable patients with mild-to-moderate HF (87.1% NYHA class II), with 51% taking loop diuretics, potentially limiting generalizability to severe HF.
• No differences were observed in critical safety outcomes including mortality, HF hospitalizations, need for IV diuretics, or acute kidney injury at six months.
• Actual fluid consumption averaged 1,764 mL in the liberal arm versus 1,480 mL in the restriction arm, confirming adequate separation between groups.
• Patients under fluid restriction experienced significantly higher thirst distress, suggesting potential negative impact on quality of life without corresponding clinical benefit.

🎯 Clinical Practice Impact 🎯

• Patient Communication: When counseling stable HF patients, clinicians can now discuss evidence that strict fluid restriction may not be necessary for most patients with mild-to-moderate symptoms. Address deeply ingrained beliefs about fluid restriction, using FRESH-UP data to potentially reduce unnecessary patient burden and improve quality of life.
• Practice Integration: Consider removing or modifying fluid restriction recommendations from standard HF discharge instructions for stable NYHA class II patients. Re-evaluate institutional protocols that automatically recommend fluid restriction for all HF patients regardless of symptom severity or clinical status.
• Risk Management: Monitor patients transitioning from restricted to liberal fluid intake, especially during medication adjustments or clinical deterioration. More severe HF cases (NYHA III-IV) may still benefit from individualized fluid management pending further studies in these populations.

More on Heart Failure (HF)