The headliner: Should patients with heart failure restrict their fluid intake?
Probably not! While we counsel patients with heart failure to fluid restrict, this was based on lousy data. The results from the FRESH-UP trial showed no significant benefit of fluid restriction over liberal fluid intake in improving health status among patients with heart failure. The trial included outpatients with heart failure (NYHA II or III), and a few key exclusions were GFR < 30, hyponatremia, and NYHA IV HF. Patients randomized to restricted fluid intake had greater “thirst distress,” which should surprise no one. Click here to listen to the Rounds Table podcast covering this trial.
Hidden gem #1: Does thoracentesis for pleural effusion from heart failure make a patient feel better?
Nope! The TAP-IT trial included patients hospitalized with decompensated heart failure who had a pleural effusion– they were randomized to thoracentesis versus no thoracentesis. The primary outcome was days alive and out of hospital by day 90. There was no difference between the two groups. However, patients who received thoracenesis had higher rate of complications compared to those without.
Hidden gem #2: Should patients be started on an SGLT2i following TAVI?
Yes! Ok, so maybe this was not a hidden gem; it was published in NEJM. Remember that many of the large trials of SGLT2i excluded patients with severe valvular disease. It is also important to highlight the inclusion criteria of this trial: heart failure plus one of GFR 25 to 76, T2DM, or EF < 40%. For this trial, SGLT2i was started at time of discharge following TAVI. The primary outcome of death from CV causes or worsening heart failure occurred in 15% of those who got dapa and 20% of those who got standard of care (HR 0.72; 95% 0.55-0.95). Notably, patients who received dapa had a higher risk of genital infection and hypotension. Want to learn more about SGLT2i? Check out https://www.sglt2rx.com/.
The take home points:
[1] Limiting fluid intake in NYHA II–III heart failure patients does not improve health status and instead leads to greater thirst distress– challenging long-standing advice to restrict fluids.
[2] Thoracentesis for pleural effusion in decompensated heart failure does not improve outcomes.
[3] SGLT2i after TAVI for patients with heart failure reduces their risk of CV death or worsening HF.