Let the drinks flow in chronic heart failure? Insights from the FRESH-UP study

Heart failure (HF) is characterized by increased neurohormonal activation leading to sodium and water retention. Consequently, sodium and fluid restriction have long been pragmatic cornerstones in the management of HF, despite the lack of high-quality evidence to support their efficacy. This meeting report reviews the recently published Fluid Restriction in Heart Failure versus Liberal Uptake (FRESH-UP) trial, an open-label, randomized controlled study comparing restricted fluid intake (1500 mL/day) with liberal intake in patients with stable, chronic HF. At 6 weeks, the observed difference in daily fluid intake between the two arms was 284 mL, which was not associated with significant differences in health-related quality of life or safety, challenging the longstanding practice of routine fluid restriction. We provide a comprehensive analysis of these findings in the context of prior evidence and conclude that liberal fluid intake appears safe in patients with stable chronic HF on optimized guideline-directed medical therapy.