Effects of limiting fluid intake on clinical and laboratory outcomes in patients with heart failure. Results of a meta-analysis of randomized controlled trials

Fluid REStriction in Heart failure versus liberal fluid UPtake: Rationale and design of the randomised FRESH-UP study

AIMS

It is common practice for clinicians to advise fluid restriction to heart failure (HF) patients, but data from clinical trials are lacking. Moreover, fluid restriction is associated with thirst distress and may adversely impact quality of life (QoL). To address this gap in evidence, the Fluid REStriction in Heart failure versus liberal fluid UPtake (FRESH-UP) study was initiated.

METHODS

The FRESH-UP study is a randomised, controlled, open-label, multicentre trial to investigate the effect of a 3-month period of liberal fluid intake versus fluid restriction (1500ml/day) on QoL in outpatient chronic HF patients (NYHA II-III). The primary aim is to assess the effect on QoL after 3 months using the Overall Summary Score of the Kansas City Cardiomyopathy Questionnaire (KCCQ). Thirst distress as assessed by the Thirst Distress Scale for patients with HF, KCCQ Clinical Summary Score, each of the KCCQ domains and clinically meaningful changes in these scores, the EQ-5D-5L, patient reported fluid intake and safety (i.e. death, HF hospitalisations) are secondary outcomes. The FRESH-UP study is registered at ClinicalTrials.gov (NCT04551729).

CONCLUSION

The results of the FRESH-UP study will substantially add to the level of evidence concerning fluid management in chronic HF and may impact QoL of these patients.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Fluid Intake Recommendation Considering the Physiological Adaptations of Adults Over 65 Years: A Critical Review

The aim of this critical review was to clarify recommended fluid intake for older people. A literature search of published articles and guidelines on fluid intake recommendations until April 2020 was carried out using PUBMED, Scopus, Cochrane, and Google Scholar. In this review, we focused on people over 65 years old at different care levels. The results show that the mean fluid intake ranges between 311 and 2390 mL/day. However, it is difficult to know whether this corresponds to the real pattern of fluid intake, due to the variability of data collection methods. With respect to the recommendations, most international organizations do not take into consideration the physiology of ageing or the health problems associated with an older population. In conclusions, we recommend to follow the guideline of the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Food Safety Authority (EFSA). ESPEN is the only guideline which takes into account age. It is also based on EFSA recommendations. This authority takes into consideration all fluids consumed (ranging from food to fluids). If it is known that around 20% of all fluids consumed come from food, the result would effectively be that the EFSA recommends the same as the ESPEN guidelines: 1.6 L/day for females and 2.0 L/day for males. The findings could help raise the awareness of professionals in the sector with respect to the required fluid intake of the elderly and, in this way, contribute to avoiding the consequences of dehydration.

Factors associated with self-care behaviours among Koreans with heart failure

BACKGROUND

Self-care behaviours are important to improve health outcomes in patients with heart failure. However, little is known about the factors related to the subdimensions of self-care behaviours in these patients.

AIMS

To identify the factors associated with the subdimensions of self-care behaviours among South Korean patients with heart failure.

METHODS

The participants in this cross-sectional descriptive study conducted between October 2016 and January 2017 were 178 patients with heart failure. Self-care behaviours were measured using the EHFScB-9, which has three subdimensions: autonomy-based adherence; provider-directed adherence; and consulting behaviours. Demographic characteristics, experience of heart failure education, physical function, patient health questionnaire-9, Pittsburgh sleep quality index and self-care confidence were also measured. Descriptive statistics and multiple linear regression analysis were conducted.

RESULTS

The mean age was 62 ± 12 years, and 37% were women. Younger age (P=0.023), no experience of heart failure education (P=0.039), poor physical function (P=0.003), poor sleep quality (P=0.037) and lower self-care confidence (P=0.001) were significantly associated with poor autonomy-based adherence. Being employed (P=0.042), poor sleep quality (P=0.042) and lower levels of self-care confidence (P=0.001) were associated with poor provider-directed adherence. Younger age (P=0.001) and lower self-care confidence (P=0.001) were associated with lower engagement in consulting behaviours.

CONCLUSION

The three subdimensions of self-care behaviours were associated with different psychosocial factors, necessitating the development of tailored interventions and educational materials based on unique self-care behaviour patterns in patients with heart failure.

Thirst in heart failure: what do we know so far?

PURPOSE OF REVIEW

Thirst is a common and burdensome symptom of heart failure, which impacts adversely on quality of life. To date, there is limited research on the prevalence of thirst, the factors associated with thirst and interventions to help manage thirst in heart failure. This review summarizes key empirical research developments of thirst.

RECENT FINDINGS

Recent research shows that the heart failure syndrome, medications, self-care practice such as fluid restriction and anxiety contributes greatly to increased thirst in patients with heart failure. In addition, predictors such as being younger, male patient, with high symptom burden and serum urea is also associated with thirst. There are no intervention studies to manage thirst, only reports of various strategies recommended to heart failure patients in clinical practice.

SUMMARY

Despite the burden of thirst in heart failure patients, strategies to relieve thirst remains insufficiently addressed in literature. Further research to improve the understanding of the severity of thirst and its relationship to possible factors associated with thirst is required in order to develop future interventions to either prevent or alleviate troublesome thirst in patients with heart failure.

Supraventricular tachycardia, pregnancy, and water: A new insight in lifesaving treatment of rhythm disorders

Pregnancy may predispose to paroxysmal supraventricular tachycardia (SVT), in subjects with or without identifiable heart disease. Many physiological conditions such as autonomic nervous system changes, altered systemic hemodynamics, etc. can contribute to the onset of arrhythmias during pregnancy. Some cases reported the occurrence of arrhythmias in relation to systemic fluid variations. We report the case of a pregnant woman who experienced SVT due to fluid depletion, detected by bioimpedance vector analysis (BIVA), which was successfully treated by water repletion under tight BIVA monitoring. Emergency physicians can overcome dangerous drug administration by considering historical examination and using fast and reproducible techniques such as BIVA.

Strategies for thirst relief: integrative literature review

Objective:

to analyze the strategies used to relieve the thirst of hospitalized patients.

Method:

an integrative review, for which the databases PubMed, LILACS, CINAHL and the group of references organized by the Group for Study and Research of Thirst were selected for the search of primary studies, with the keywords: thirst, ice, cold, intervention, nursing care, artificial saliva.

Results:

the review sample was composed of ten primary studies. The strategies found were: low temperature using frozen gauze, ice chips, and cold water, menthol associated with cold strategies, chewing gum, acupressure, and the use of a thin straw, substitute saliva, and early fluid ingestion.

Conclusion:

the temperature was presented as a predominant and effective strategy to relieve the thirst for surgical patients in intensive care and hemodialysis treatment.

Dietary Self-management in Heart Failure: High Tech or High Touch?

OPINION STATEMENT

Dietary management of heart failure (HF) has largely been focused on sodium and fluid restrictions. Although safety and efficacy of these interventions in HF remain unclear, a daily sodium intake between 2000 and 3000 mg/day appears to be safe in these patients. Ongoing clinical research will inform on the safety and efficacy of a more restrictive sodium intake to less than 1500 mg/day. Data shows that routine fluid restriction in HF regardless of symptoms may be unnecessary; however, in patients with signs of congestion, fluid restriction to 2.0 L/day may be advisable. Recently, more attention has been paid to other nutritional aspects of HF beyond sodium and fluid intake, although there is still little evidence available to guide nutritional management of HF. Assuring that patients meet daily requirements for key micronutrients, such as calcium, magnesium, potassium, folate, vitamin E, vitamin D, zinc, and thiamine, is essential in order to prevent deficiencies. More appropriate macronutrient composition of the diet is still to be determined; however, a diet containing 50-55% carbohydrates, 25-30% fat, and 15-20% protein seems acceptable for patients with HF with or without non-end-stage renal disease. Additionally, increased protein intake may be considered in malnourished/cachectic patients. Consulting a registered dietitian is especially helpful for patients with recent HF exacerbations or for patients with multiple comorbidities who may need to follow several dietary restrictions and may benefit of individualized dietary counseling in order to ensure appropriate intake of energy, protein, and micronutrients. Today, there are still several knowledge gaps in guiding the dietary management of HF. In this article, we review current recommendations for the dietary management of HF and the evidence supporting this practice.

Fluid restriction in patients with heart failure: how should we think?

BACKGROUND/AIM

Fluid restriction has long been considered one of the cornerstones in self-care management of patients with heart failure. The aim of this discussion paper is to discuss fluid restriction in heart failure and propose advice about fluid intake in heart failure patients.

RESULTS

Although there have been seven randomised studies on fluid restriction in heart failure patients, the effect of fluid restriction on its own were only evaluated in two studies. In both studies, a stringent fluid restriction compared to a liberal fluid intake was not more beneficial with regard to clinical stability or body weight. In the other studies fluid restriction was part of a larger study intervention including, for example, individualised dietary recommendations and follow-up by telephone. Thus, the effect of fluid restriction on its own has been poorly evaluated.

CONCLUSION

Fluid restriction should not be recommended to all heart failure patients. However, temporary fluid restriction can be considered in decompensated heart failure and/or patients with hyponatremia. Tailored fluid restriction based on body weight (30 ml/kg per day) seems to be most reasonable. To increase adherence to temporary fluid restriction, education, support and planned evaluations can be recommended.