Traditionally, fluid restriction is recommended for patients with heart failure (HF) to avoid congestion.¹ However, the 2022 American Heart Association/American College of Cardiology/ Heart Failure Society of America (AHA/ACC/HFSA) Guideline for the Management of Heart Failure notes that evidence supporting this practice is of low quality.¹ The guideline also identifies the role of fluid restriction in preventing and treating HF as an evidence gap warranting further investigation.¹At the ACC Annual Scientific Session 2025, Dr. Roland RJ van Kimmenade of the Department of Cardiology, Radboud University Medical Center in the Netherlands, presented findings from the FRESH-UP trial.¹ 

The FRESH-UP trial (Fluid REStriction in Heart failure vs. liberal fluid UPtake) was a randomized, open-label, multicenter study that explored the effects of liberal fluid intake vs. fluid restriction in patients with chronic HF.¹ Adults aged ≥18 years with a diagnosis of chronic HF (as defined by European Society of Cardiology [ESC] guidelines for >6 months) and classified as New York Heart Association (NYHA) class II or III were eligible.¹ Key exclusion criteria included recent (within 2 weeks) changes in HF medication, recent hospitalization for HF and recent 

coronary interventions (percutaneous coronary intervention, coronary artery bypass grafting) or device implantation (pacemaker, cardiac resynchronization therapy or implantable cardioverter-defibrillator) within 3 months prior to randomization.1 Patients with hyponatremia (sodium <130mmol/L) or an estimated glomerular filtration rate (eGFR) <30mL/min/1.73m² at baseline were also excluded.¹ 

Following baseline assessments, participants were randomized 1:1 to either a liberal fluid intake group (n=254), who were allowed unlimited fluid intake, or a fluid restriction group (n=250), with a maximum intake of 1,500mL/day.1 Daily fluid intake was reported at week 6, with health status assessed at month 3 and continued follow-up for 6 months.¹ The primary outcome was health status at 3 months, measured using the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS).¹ The key secondary outcome was thirst distress, assessed by the Thirst Distress Scale for patients with HF (TDS-HF).1 Baseline characteristics were balanced between groups.¹ Most participants were male, had NYHA class II symptoms, and HF with reduced ejection fraction.¹ Approximately half had ischemic HF, and 45%-50% in both arms reported liberal fluid intake at baseline.1 Use of standard HF medications was common, including loop diuretics in about 50% of patients.¹ 

The mean fluid intake was 1,764mL in the liberal group and 1,480mL in the restricted group (p<0.001), aligning with the typical intake for this age group/population.¹ At 3 months, no statistically significant difference was observed in the primary outcome: KCCQ-OSS was 74.0 in the liberal fluid group vs. 72.2 in the fluid restriction group (adjusted mean difference=2.17 points; 95% CI: -0.06 to 4.39; p=0.06).¹ Subgroup analyses (including gender, age, NYHA class, NT-proBNP, body mass index [BMI], sodium, urea, creatinine, loop diuretic use, and diabetes) showed no significant interaction.¹ However, TDS-HF was significantly lower in the liberal intake group (16.9 vs. 18.6; p<0.001).¹ There were no significant differences in mortality, HF hospitalizations, need for intravenous diuretics, or incidence of acute kidney injury at 6 months.¹ 

In conclusion, while the primary endpoint was not met, liberal fluid intake was a s sociated with improved patient-repor ted well-being, and reduced thirst distress, with no safety concerns identified.¹ Therefore, findings from the FRESH-UP trial challenge the routine use of fluid restriction in chronic HF management and support a more individualized approach to fluid intake.¹ As Dr. van Kimmenade noted, “The FRESH-UP study questions the benefit of fluid restriction in chronic HF.” 

"The FRESH-UP study questions the benefit of fluid restriction in chronic HF“ 

Dr. Rolad RJ van Kimmenade 

Radboud University Medical Center, 

Nimegen, Netherlands

In an interview with Omnihealth Practice, Dr. Ong, Hean-Jin Aaron, a consultant cardiologist from Malaysia, shared his insights into the challenges and evolving approaches to managing chronic HF, particularly in fluid management and personalized care strategies. 

1. What defines chronic HF in clinical practice? How do patients with HF typically present? 

Dr. Ong: Chronic HF is a clinical syndrome where the heart fails to meet the metabolic demands of the body due to persistent structural or functional cardiac impairment. This results in reduced cardiac output or diastolic dysfunction. Patients with HF often present with signs and symptoms of volume overload: dyspnea, pulmonary congestions, peripheral edema, or even ascites. 

2. Once HF is suspected, what is the usual diagnostic pathway and first-line treatment, especially for those with HFrEF? 

Dr. Ong: Diagnosis hinges on clinical acumen, supported by echocardiography and NT-proBNP levels, though access to the latter may be limited in certain healthcare settings. If HF with reduced ejection fraction (HFrEF) is confirmed, we initiate guideline-directed therapy built on the “four pillars”: renin-angiotensin-aldosterone system (RAAS) inhibitors (including angiotensin receptor-neprilysin inhibitor [ARNI]), beta-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRAs). Non-pharmacological strategies, like sodium restriction (<2g/day) and fluid restriction (typically 500-1,500mL/day), are often recommended, especially in patients with advanced CKD or recurrent decompensations. Still, challenges remain. Patient adherence can falter due to poor symptom recognition or polypharmacy burdens, particularly in older adults with multiple comorbidities. Despite major advances, HF still carries a mortality rate comparable to certain cancers. 

3. Fluid restriction is often part of the management plan for HF patients, but is it still considered a standard of care, or are there evolving perspectives on this approach? 

Dr. Ong: While fluid restriction has been traditionally recommended, we now understand that rigid limits may not suit every patient. Over-restriction of fluid coupled with concurrent diuretic effects of multiple HF medications can provoke issues like postural hypotension, dehydration, and renal dysfunction. The FRESH-UP trial adds weight to this evolving view. While the trial’s results may not be fully generalizable to populations in Asia, where differences in dietary sodium intake, body weight, and climatic conditions can influence fluid balance, it underscores the importance of personalized management. Increasingly, we encourage a patient-led approach, where individuals, particularly those with stable disease, are empowered to adjust their fluid intake or even titrate diuretics like frusemide based on daily weight and symptoms, in close consultation with their care team.