Aggressive salt and water restriction in acutely decompensated heart failure: is it worth its weight in salt?

Abstract

Evaluation of: Aliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern. Med. 173(12), 1058–1064 (2013).

Acute decompensated heart failure (ADHF) is the leading cause of hospitalization worldwide, especially in the elderly, and is associated with a high readmission rate and increased first year mortality . Fluid overload manifested by pulmonary congestion is seen in the majority of patients with ADHF and is believed to be the reason behind most admissions. ADHF is commonly treated with intravenous diuretics aimed to alleviate congestion and restore euvolemia. In fact, current European and American guidelines for heart failure (HF) consider relief of congestion as the first-line therapy in ADHF. Following the same theme of reducing fluid retention, historical approaches have recommended water and salt restriction as an essential non-pharmacological therapy in the management of symptomatic HF. This ‘common sense’ dietary practice was mainly based on experts’ opinions and has been challenged by recent data suggesting that salt or fluid restriction has neutral outcomes in achieving clinical stability and improving signs and symptoms of HF .

Keywords::

• acute
• heart failure
• restriction
• salt
• sodium
• water

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Acute decompensated heart failure (ADHF) is a syndrome with heterogeneous etiologies and complex interactions involving hemodynamics, vascular compliance, neurohormonal activations and inflammatory cascades leading to pulmonary congestion.

• • Pathophysiology of volume overload in ADHF is not well understood.

• • Sodium and water restriction are used in the management of ADHF but the benefits of each are still unclear and subject to debate.

• • Aggressive salt and water restriction has demonstrated neutral effects on congestive parameters as well as increased thirst in recent small trials, but this could be due to an exaggerated activation of the neurohormonal pathways.

• • Larger, randomized, multicentered trials that take into account the neurohormonal milieu in various salt and water loading conditions are required before we can fully identify the appropriate intake of salt and fluid in ADHF.

• • Until further data are available, the reasonable salt restriction advocated by the current ACCF/AHA guidelines should remain the foundation of this non-pharmacological therapy in symptomatic heart failure patients.