Optimal fluid management strategies in patients with heart failure: a systematic review and meta-analysis of randomized controlled trials

TL;DR

This study finds that fluid restriction in heart failure patients does not improve outcomes and may reduce adherence, suggesting a need for personalized fluid management strategies.

Contribution

The study provides the first meta-analysis comparing fluid restriction and liberal fluid intake in heart failure patients using randomized controlled trials.

Findings

Fluid restriction significantly reduced fluid intake but did not improve clinical outcomes like mortality or rehospitalization.

Patients on fluid restriction had lower adherence compared to those with liberal fluid intake.

No significant differences were found in quality of life or acute kidney injury between the two groups.

Abstract

Fluid restriction is frequently recommended in heart failure (HF) management to prevent volume overload and improve clinical outcomes. However, the evidence supporting this practice remains limited. This meta-analysis aimed to evaluate the impact of fluid restriction vs. liberal fluid intake on clinical and patient-centered outcomes in individuals with HF.

A systematic search of PubMed, Embase, Cochrane Library, and ClinicalTrials.gov was conducted through April 27, 2025, to identify randomized controlled trials (RCTs) comparing restrictive and liberal fluid strategies in HF. Pooled risk ratios (RRs) for binary outcomes and weighted mean differences (WMDs) for continuous outcomes with 95% confidence intervals (CIs) were calculated using a random-effects model.

Four RCTs with a total of 747 patients were included, of whom 378 (50.6%) were randomized to liberal fluid intake. There were no significant differences between groups regarding all-cause mortality (RR: 1.71; 95% CI: 0.37–3.72; p = 0.27), HF rehospitalization (RR: 0.71; 95% CI: 0.46–1.10; p = 0.13) or thirst (WMD: 4.78; 95% CI: −6.72 to −16.28; p = 0.42). Patients in the fluid restriction group had significantly lower fluid intake (WMD: −361.84 mL/day; 95% CI: −552.89 to −170.78; p < 0.001) and lower adherence (WMD: 16.47; 95% CI: 6.45–26.50; p = 0.001). No significant differences were observed between groups in terms of acute kidney injury, weight loss, or patient-reported quality of life, and Kansas City Cardiomyopathy Questionnaire (KCCQ) Clinical summary score.

In this meta-analysis, fluid restriction significantly reduced total fluid intake but did not improve clinical outcomes in patients with HF. Adherence was higher with liberal fluid intake. These findings support an individualized approach to fluid management in patients with HF.

PROSPERO CRD420251048914.

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