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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e956

CLINICAL STATEMENTS AND GUIDELINES

HF specialists and other members of the multidisciplinary team may help ensure that the patient has adequate information to make an informed decision.

8.2 Nonpharmacological Management: Advanced HF

Recommendation for Nonpharmacological Management: Advanced HF

COR LOE Recommendation

2b C-LD 1.	 For patients with advanced HF and hyponatremia, the benefit of fluid restriction to reduce congestive symptoms is uncertain.1–4

Synopsis Hyponatremia and diuretic-refractory congestion is common in advanced HF and is associated with poor clinical5,6 and patient-reported outcomes.7 Moreover, improvement in hyponatremia has been shown to improve clinical outcomes.8,9 Fluid restriction is commonly prescribed for patients with hyponatremia in acute HF but only improves hyponatremia modestly.1 Although restricting fluid is a common recommendation for patients with HF, evidence in this area is of low quality,10 and many studies have not included patients with advanced HF specifically. Moreover, fluid restric- tion has limited-to-no effect on clinical outcomes or diuretic use.4 Although HF nutritional counseling typically focuses on restricting sodium and fluid, patients with advanced HF have the greatest risk of developing cachexia or malnutrition.11 Hence, dietary restrictions and recommendation should be both evidence-based and comprehensive.

Recommendation-Specific Supportive Text

1.	 In a registry study of hyponatremia in acute decompensated HF, fluid restriction only improved hyponatremia marginally.1 A registered dietitian-guided fluid and sodium restriction intervention improved NYHA functional classification and leg edema in patients with HFrEF who were not in stage D HF,2 and fluid restriction improved QOL in a pilot RCT of patients with HFrEF and HFpEF (NYHA class I to IV).3 In a meta-analysis of RCTs on fluid restriction in HF in general, restricted fluid intake compared with free fluid consumption did not result in reduced hospitalization or mortality rates, changes in thirst, the duration of intravenous diuretic use, serum creatinine, or serum sodium levels.4 The validity of a previous trial supporting clinical benefits of fluid restriction in HF is in serious question.12

Table 17.  INTERMACS Profiles Profile* Profile Description Features 1 Critical cardiogenic shock Life-threatening hypotension and rapidly escalating inotropic/pressor support, with critical organ hypoperfusion often confirmed by worsening acidosis and lactate levels. 2 Progressive decline “Dependent” on inotropic support but nonetheless shows signs of continuing deterioration in nutrition, renal function, fluid retention, or other major status indicator. Can also apply to a patient with refractory volume overload, perhaps with evidence of impaired perfusion, in whom inotropic infusions cannot be maintained because of tachyarrhythmias, clinical ischemia, or other intolerance. 3 Stable but inotrope dependent Clinically stable on mild-moderate doses of intravenous inotropes (or has a temporary circulatory support device) after repeated documentation of failure to wean without symptomatic hypotension, worsening symptoms, or progressive organ dysfunction (usually renal).

4 Resting symptoms on oral therapy at home Patient who is at home on oral therapy but frequently has symptoms of congestion at rest or with activities of daily living (dressing or bathing). He or she may have orthopnea, shortness of breath during dressing or bathing, gastrointestinal symptoms (abdominal discomfort, nausea, poor appetite), disabling ascites, or severe lower extremity edema.

5 Exertion intolerant Patient who is comfortable at rest but unable to engage in any activity, living predominantly within the house or housebound. 6 Exertion limited Patient who is comfortable at rest without evidence of fluid overload but who is able to do some mild activity. Activities of daily living are comfortable, and minor activities outside the home such as visiting friends or going to a restaurant can be performed, but fatigue results within a few minutes or with any meaningful physical exertion. 7 Advanced NYHA class III Patient who is clinically stable with a reasonable level of comfortable activity, despite a history of previous decompensation that is not recent. This patient is usually able to walk more than a block. Any decompensation requiring intravenous diuretics or hospitalization within the previous month should make this person a Patient Profile 6 or lower. ICD indicates implantable cardioverter-defibrillator; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; and NYHA, New York Heart Association. Adapted from Stevenson et al,7 with permission from the International Society for Heart and Lung Transplantation. *Modifier options: Profiles 3 to 6 can be modified for patients with recurrent decompensations leading to frequent (generally at least 2 in past 3 mo or 3 in past 6 mo) emergency department visits or hospitalizations for intravenous diuretics, ultrafiltration, or brief inotropic therapy. Profile 3 can be modified in this manner if the patient is usually at home. If a Profile 7 patient meets the modification of frequent hospitalizations, the patient should be moved to Profile 6 or worse. Other modifier options include arrhythmia, which should be used in the presence of recurrent ventricular tachyarrhythmias contributing to the overall clinical course (eg, frequent ICD shocks or requirement of external defibrillation, usually more than twice weekly); or temporary circulatory support for hospitalized patients Profiles 1 to 3.

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