Fluid Restriction Does Not Help People with Chronic Heart Failure

• Globally, around 26 million people are affected — In the U.S., around 960,000 new cases are diagnosed each year. Today, it’s estimated that 6.5 million Americans have heart failure.¹

• Heart failure affects one or both sides of the heart — The heart is separated into four chambers. The bottom two chambers called the ventricles, pump blood to the lungs or the body, and heart failure develops when these become inefficient. When there is left ventricular failure, a person experiences fatigue and shortness of breath. With right ventricular failure, a person may experience abdominal and peripheral fluid buildup.²

• It develops from a variety of different factors that place excessive demand on the heart — One factor is long-term, uncontrolled high blood pressure or hormonal disorders such as hyperthyroidism. However, the primary cause of heart failure is coronary artery disease, which reduces the delivery of oxygen and nutrients to the heart muscle. Over time, this leads to impaired function.

• Heart failure manifests in ways that are hard to ignore — Fluid buildup in the legs and lungs, shortness of breath with minimal effort, constant fatigue, and a persistent feeling of heaviness in the chest are just some symptoms associated with this condition. When left untreated or poorly managed, heart failure raises the risk of kidney failure, cognitive decline, and premature death.

• Despite advances in drug therapy, the prognosis continues to remain poor — Individuals with severe heart failure have a mortality rate of up to 60% over one year and up to 30% mortality rate in mild to moderate failure.³

• The study involved 504 patients with mild, stable heart failure symptoms — According to an article from News-Medical.net, “Study participants were 69 years old on average, [and] about two-thirds were men … About half of the participants had heart failure with reduced ejection fraction and half had preserved ejection fraction, representing the two types of heart failure.”⁷

Most of the participants were classified as New York Heart Association (NYHA) Class II, meaning they had mild symptoms during ordinary activity but were comfortable at rest.⁸

• Participants were randomly assigned to one of two groups — One group was restricted to 1,500 milliliters per day (about six cups of water) and the other was allowed to drink as much as they wanted. Importantly, this wasn’t a theoretical restriction — it was something patients had to follow every day for three months.

• There was no real difference in health status between the two groups — The group that followed a fluid restriction didn’t see any meaningful difference in the most important measure of their health status.

Researchers used a standardized tool called the Kansas City Cardiomyopathy Questionnaire (KCCQ), which assesses how much heart failure affects symptoms, daily life, and quality of life. The result? Those who drank freely actually scored slightly better. Their KCCQ overall score was 74.0, compared to 72.2 in the fluid-restricted group.

• Patients who were restricted felt thirstier and less comfortable — What was significant, however, was thirst. The restricted group reported much higher levels of thirst distress, which creates unnecessary discomfort and reduces quality of life.⁹

• Drinking more did not increase risk for any health complications — Doctors believe that if people with heart failure drink too much, they’ll end up back in the hospital or experience kidney damage. But this study’s data dismantled that assumption. There were no differences between the two groups in terms of deaths, hospitalizations, emergency diuretic use, or acute kidney injury after six months. That means drinking more did not raise any health risks.¹⁰

• Many patients who drank more than the limit still did just fine — Nearly three-quarters of people in the liberal intake group drank more than the “allowed” 1,500 ml per day. What’s more, over one-third of those in that group consumed more than 2,000 ml daily — and still showed no adverse effects. The implication here is massive — it means you don’t need to live with constant thirst or count every sip just to stay safe. You just need to listen to your body.

• Even small increases in fluid made a meaningful difference in how people felt — Those in the restricted group averaged about 1,488 ml of fluid per day, while those in the unrestricted group came in at 1,764 ml. That’s just under 10 ounces more each day — roughly the size of a small bottle of water. But that small margin meant the difference between feeling constantly thirsty or comfortably hydrated.

• Restricting fluids causes the body to trigger stress hormones that work against healing — Thirst is a biological stress signal. When your body feels deprived of water, it activates hormonal systems like vasopressin and adrenaline, as well as the sympathetic nervous system, which increases heart rate, blood pressure, and stress hormone levels.

Over time, that contributes to a physiological state that works against healing. What the FRESH-UP study shows is that forcing fluid restriction may be pushing your body into exactly the type of state heart failure treatment is trying to avoid.

• “A patient-driven study” — According to Dr. Roland van Kimmenade, a cardiologist at Radboud University Medical Center in Nijmegen, Netherlands, and the study’s senior author, patients were frustrated by the advice they were being given and wanted proof that it worked. “This study was really inspired by the patients. Patients said: ‘You are giving us this advice. I don’t like it. Why are you giving it? How is it helping me?’”

• Fluid restriction is based on low-quality evidence, and that’s finally being questioned — One of the strongest messages in the article is the reminder that fluid restriction has always been rooted in low-quality evidence. Even the American Heart Association and the Heart Failure Society of America have already acknowledged that the support for this recommendation was weak, but the habit had stuck around in practice.

• Experts are now openly recommending a more flexible approach — Doctors like Dr. Shelley Hall from Baylor Scott & White Health praised the trial for giving clinicians the evidence they’ve long needed to challenge rigid guidelines. “I was actually delighted to see the results of this trial [to be able to say] we were right: 2 liters is absolutely fine,” she said.

Her advice moving forward is to drink when you’re thirsty — but don’t drown yourself, and don’t punish yourself either. “What I would take away from this trial is let’s be a little kinder to our patients and ourselves, that we don’t probably have to be so harsh in pounding fluid restriction,” she commented.¹³

• Researchers found no benefit (and some harm) in restricting fluids in stable patients — The review, which specifically addressed patients with chronic heart failure, found no reliable data proving that this approach improves life expectancy, reduces hospitalizations, or lowers symptom burden.

In fact, they argued the opposite — rigid fluid limits might increase discomfort, reduce patient satisfaction, and even trigger compensatory biological stress responses that worsen outcomes.

• The study explained how your body overcorrects when you drink too little — When you drink less, your body compensates by increasing vasopressin, a hormone that tells the kidneys to hold onto water. While that might sound helpful, this process also raises blood pressure and heart strain. It’s a hormonal overcorrection that often leads to worsening symptoms over time.

• Fluid restriction triggers a harmful stress response that wears down your heart — More importantly, they pointed out that fluid restriction increases something called “neurohormonal activation” — basically, your body gets stuck in a fight-or-flight mode. It pumps out stress hormones, tightens your blood vessels, and makes the heart work harder. This constant pressure wears down the body, especially when you’re already dealing with a weakened heart.

• Too much restriction of both water and salt causes serious danger — The review also dove into sodium restriction, which is frequently prescribed alongside fluid limits. But once again, the evidence was thin. Combining sodium and fluid restriction didn’t consistently lead to better outcomes.

And the authors raised a red flag — too much restriction of both water and salt leads to hyponatremia (dangerously low blood sodium levels). This triggers confusion, seizures, and in some cases, even death. So, in trying to “protect” the heart, this approach may set up other systems to fail.

• They recommend tracking smarter, not drinking less — The study also called on physicians to rethink how they monitor fluid status. Instead of obsessing over fluid intake logs, the authors recommended more precise methods like checking for weight changes, measuring lab values like serum sodium, and monitoring how you feel on a day-to-day basis.

These are more accurate indicators of whether your body is holding onto too much fluid — and they’re easier for you to understand and track.

1. Don’t force fluid restriction if your condition is stable and you’re already on proper meds — If you’re taking heart failure medications and your doctor has told you your condition is “stable,” there is no benefit to sticking to a 1,500 ml rule. Drink when you’re thirsty, not based on a one-size-fits-all rule that makes your day harder and your body more stressed.

2. Support your body’s natural fluid regulation by optimizing sodium and potassium balance — Most people with fluid retention issues are told to cut sodium, but that’s only part of the picture. You need enough balanced sodium and potassium to support proper kidney function and fluid exchange.

If you’re eating mostly processed food or using salt substitutes without understanding your ratios, you’re likely out of balance. Add potassium-rich foods like cooked potatoes, squash, ripe fruits, or coconut water to your meals (unless you’ve been diagnosed with high potassium, of course). You’ll find more healthy food options in this article: “How Potassium Can Help Your High Blood Pressure.”

3. Track your thirst, weight, and energy, not just your water intake — If you want real control over your health, start paying attention to how you feel day to day. Is your weight climbing rapidly overnight? That’s a sign of fluid buildup. Are your rings tight or your ankles puffy? That’s more reliable than any cup count. Are you constantly tired or thirsty despite following instructions? That means something isn’t working. Your body is the best monitor — start using it.

4. Don’t ignore the stress hormone impact of dehydration — When you restrict fluids too aggressively, your body releases stress hormones like vasopressin and adrenaline. These chemicals raise your blood pressure, constrict blood vessels, and make your heart work harder — not easier.

If you’re always anxious, wired, or fatigued while restricting fluids, that’s your nervous system pushing back. Respect the signals and ease off. Thirst is your body’s way of asking for support, not a mistake.

5. Rebuild your confidence in your own decision-making — If you’ve been trained to follow instructions without understanding them, it’s easy to lose touch with what you know about your body. Start rebuilding trust in yourself. If you’re thirsty, drink. If you’re bloated or gaining weight, adjust your intake and food quality. Your intuition and daily feedback are valid tools, just like lab results or prescriptions.