Beyond Diursesis: Rethinking Fluid and Sodium Strategies in Heart Failure

Heart failure (HF) remains a major global burden, with high morbidity, mortality, and healthcare costs driven largely by recurrent hospitalizations. While guideline-directed therapy has advanced considerably, fluid and sodium management remain among the least standardized aspects of HF care. Traditional practices of strict fluid and sodium restriction have recently been challenged by contemporary evidence. In the acute setting, loop diuretics remain the cornerstone of therapy, with early titration, sequential nephron blockade, and close monitoring being essential for achieving effective decongestion without compromising renal function. Trials such as acetazolamide decompensated heart failure with volume overload (ADVOR) and diuretic optimization strategies evaluation (DOSE) have refined strategies for diuretic use, while ultrafiltration is reserved for refractory cases. Subcutaneous furosemide has also emerged as a short-term option for parenteral diuresis outside the hospital, providing intravenous-equivalent pharmacokinetics, improving decongestion and dyspnea, and potentially reducing hospitalizations. In the outpatient setting, evidence from fluid restriction in heart failure versus liberal fluid uptake (FRESH-UP) and study of dietary intervention under 100 Mmol in heart failure (SODIUM-HF) demonstrates that routine fluid restriction and aggressive sodium restriction do not improve outcomes and may worsen quality of life. Instead, individualized and patient-centered approaches such as liberal fluid intake guided by thirst and moderate sodium restriction consistent with general cardiovascular guidelines represent safe and practical strategies. Moving forward, distinguishing true volume overload from redistribution, integrating objective tools such as lung ultrasound and bioimpedance, and applying precision approaches with real-time monitoring and artificial intelligence (AI)-driven models may advance care. Fluid and sodium management should prioritize outcomes and quality of life rather than rigid restrictions.