Unlocking Heart Health: New Guidelines on Sodium and Fluid Intake in Heart Failure Released by ESC

Heart failure (HF), a chronic condition affecting millions worldwide, imposes significant demands on healthcare systems and individuals alike. The delicate balance of sodium and fluid intake is central to its management, which directly influences cardiovascular function and symptom severity. The guideline, published in the European Journal of Heart Failure, underscores the need for tailored dietary approaches, acknowledging that individualized strategies are pivotal in mitigating symptoms and reducing hospitalizations.

For these guidelines, individuals with acute HF are those who, during the uptitration phase of guideline-recommended HF therapy (GDMT), have residual congestion and require maintenance on loop diuretics. Patients with chronic HF are those with chronic stable HF who are receiving GDMT and don’t have congestion signs/symptoms, and who have no or minimal loop diuretic requirements.

The ESC advises limiting salt intake to no more than 5 g/day in HF patients and restricting fluids to 1.5-2 L/day only in select patients with HF.

Sodium Intake

Normal sodium intake is generally considered 1.5 to 4 g/day (equivalent to 3.75-10 g of salt daily); a more liberal sodium intake is over 4 g/day; and a more restrictive salt intake is limited to less than 1-1.5 g/day.

In acute HF, a liberal sodium intake may not be tolerated; thus, the ESC indicates that a normal sodium intake is likely the best strategy, provided that the overall net sodium balance (intake vs output) remains negative during the acute decongestion phase. Avoid extreme salt restriction (<1-1.5 L/day) as it may be harmful in most clinical settings.

In chronic HF, the ESC suggests a normal sodium intake, with a more liberal intake allowed up to 5 g/day.

Fluid Intake

Currently, no convincing evidence exists for a clear benefit of hypertonic saline addition during the treatment of acute decompensated HF.

Avoid large volumes of fluid intake for all HF patients. Normal fluid intake is generally considered to be 1.5 to 2.5 L/day (corresponding to 15-30 mL/kg/day); a more liberal fluid policy is over 2.5-3.0 L/day; and a restrictive fluid policy is typically one that is less than 1-1.5 L/day.

The ESC suggests a normal fluid intake in acute and chronic HF, mainly using a sense of thirst and environmental factors to guide intake.

Intensive Care Unit Patients

Use similar principles as those above for managing HF patients who are not able to eat and drink independently and are receiving sodium and fluids via intravenous lines or a gastric tube. In clinically stable patients, the goal is to achieve a daily intake like a normal sodium and fluid regimen. When febrile or acutely ill, individuals on ventilation may have more fluid intake requirements.

It is crucial to consider concurrently administered fluids with medications and flushes (fluid creep) and extravascular volume collections. Monitor diuresis and track the net effect over several days, adjusting as required.

In conclusion, the clinical consensus statement on dietary sodium and fluid intake in heart failure represents a landmark initiative aimed at refining therapeutic approaches and improving the outcomes of patients. With a focus on evidence-based recommendations and individualized care, the statement sets a new standard in cardiovascular management, underscoring the commitment of ESC to advancing patient-centered care in heart failure.

Reference:

Mullens, W., Damman, K., Dhont, S., Banerjee, D., Bayes-Genis, A., Cannata, A., Chioncel, O., Cikes, M., Ezekowitz, J., Flammer, A. J., Martens, P., Mebazaa, A., Mentz, R. J., Miró, Ò., Moura, B., Nunez, J., Ter Maaten, J. M., Testani, J., Verbrugge, F. H., . . . Filippatos, G. (2024). Dietary sodium and fluid intake in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC. European Journal of Heart Failure, 26(4), 730-741. https://doi.org/10.1002/ejhf.3244