Fluid Restriction in HF: Let’s Not Torture Patients

Drs Piña and Hsich discuss the FRESH-UP trial that challenged the dogma of fluid restriction in heart failure and provide practical strategies for optimizing medical therapy instead.
https://www.medscape.com/viewarticle/fluid-restriction-hf-lets-not-torture-patients-2025a10008ff?src=soc_yt

-- TRANSCRIPT --
Ileana L. Piña, MD, MPH: Hello and welcome. I'm Ileana Piña. I'm professor of medicine at Thomas Jefferson University Hospital and the quality chief for the cardiovascular line, and we are here in Chicago at the American College of Cardiology meeting, which is celebrating its 75th anniversary of exciting work.

I am absolutely thrilled to have as my guest Dr Eileen Hsich. She is director of heart transplant at the Cleveland Clinic, and today we're going to talk about the FRESH-UP trial.

We don't do studies like this often, where we are determining fluid balance, nutritional balance, electrolytes, sodium, and yet they become very important in a patient's life, because after they leave us, they still have to live in that real world. Eileen, tell us about FRESH-UP.

The FRESH-UP Trial

Eileen M. Hsich, MD: It's a relatively small trial.

Piña: About 200 in each patient group?

Hsich: Yes,comparing fluid restriction — 1500 milliliters a day — to a liberal strategy of drinking what you want, and doing so in a cohort that doesn't have much heart failure symptoms, mostly New York Heart Association Class II, although they did include some Class III.

Piña: Was this HFrEF (heart failure with reduced ejection fraction)?

Hsich: It was all ejection fractions. The mean was 40%; half of them were HFrEF, but it included mid-range and HFpEF (heart failure with preserved ejection fraction).

It was a multicenter study that, although small, did try to replicate real-life experiences.

Piña: How many women were there?

Hsich: About a third of the patients were female.

Piña: That's not too bad.

Hsich: They really wanted to know about quality of life. That was really the primary endpoint, using the Kansas City questionnaire

Piña: Did they have anything else to look at thirst, specifically how the patients felt about being thirsty?

Hsich: Not as their primary endpoint. [Editor’s note: The Thirst Distress Scale for Patients With Heart Failure (TDS-HF) at 3 months was a secondary endpoint.]

Piña: So the primary endpoint was purely the KCCQ (Kansas City Cardiomyopathy Questionnaire).

Hsich: And they followed them for 30 days for the primary endpoint — relatively short.

Piña: That should be enough to see differences or something like fluid.

Hsich: They didn't really find many differences. It seemed to be similar, except that there was a slight preference for the liberal strategy.

Piña: Was it safe?

Hsich: And it was safe.

Piña: That's a very important point. Because our nursing pool on the floor think that if the patient has too many fluids, then they're going to require more diuretic, and they're going to get puffy and they're going to get swollen.

Transcript in its entirety can be found by clicking here:
https://www.medscape.com/viewarticle/fluid-restriction-hf-lets-not-torture-patients-2025a10008ff?src=soc_yt