New Study Questions Fluid Restriction in Heart Failure Management

A groundbreaking study presented at the American College of Cardiology’s Annual Scientific Session (ACC.25) challenges the long-held recommendation of fluid restriction for heart failure patients. The FRESH-UP trial, a large randomized controlled study, provides fresh insights that could change how patients manage heart failure.

Study Overview and Key Findings

Heart failure, a condition where the heart struggles to pump blood effectively, often leads to congestion—causing swelling and shortness of breath. Traditionally, U.S. and European guidelines have recommended limiting fluid intake to around six cups (1,500 mL) per day to reduce these symptoms. However, the new research suggests that restricting fluids may not significantly improve patient health.

• Primary Outcome: The study enrolled 504 heart failure patients from seven centers in the Netherlands. Participants were divided into two groups: one restricted to 1,500 mL of fluid daily, and the other allowed to drink freely. After three months, no statistically significant difference in health status was observed between the two groups as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ).

• Thirst and Safety: Patients on the restricted diet reported higher levels of thirst, yet there were no differences in safety outcomes such as hospitalizations, need for intravenous diuretics, or acute kidney injury.

Implications for Heart Failure Patients

According to Dr. Roland van Kimmenade, a cardiologist at Radboud University Medical Center and the study’s senior author, these findings suggest that stable heart failure patients may not require strict fluid restrictions. This could lead to an immediate shift in treatment practices worldwide, potentially easing the daily management challenges faced by heart failure patients.

Study Design and Considerations

The FRESH-UP trial is notable for being the first large-scale study to compare liberal versus restricted fluid intake in this patient population. Key details include:

• Patient Demographics: The average participant was 69 years old, with approximately two-thirds being male. The study included both patients with reduced and preserved ejection fraction, reflecting the two main types of heart failure.

• Modest Fluid Intake Differences: The difference in average daily fluid consumption was less than 10 ounces between the two groups, which might have influenced the study’s overall results.

• Prior Advice Variability: Nearly half of the patients had not been previously advised to restrict fluids, which could have contributed to the non-significant differences observed in the study outcomes.

Broader Impact on Clinical Guidelines

The study, published online in Nature Medicine and funded by the Dutch Heart Foundation along with inter-university grants, suggests that the current guidelines advocating fluid restriction may need to be revisited. Although conducted in the Netherlands, researchers believe these results are applicable to other developed countries, potentially influencing global heart failure management practices.

Conclusion

This new evidence prompts healthcare providers to reconsider the necessity of fluid restriction in patients with stable heart failure. The research underlines the importance of personalized treatment strategies that focus on improving quality of life without imposing unnecessary limitations. For heart failure patients and clinicians alike, these findings mark a significant step toward more flexible and patient-friendly management protocols.

For more information: Herrmann, J. J., et al. (2025). Liberal fluid intake versus fluid restriction in chronic heart failure: a randomized clinical trial. Nature Medicine. doi.org/10.1038/s41591-025-03628-4.