Aggressive salt and water restriction in acutely decompensated heart failure: is it worth its weight in salt?

Acute decompensated heart failure (ADHF) is the leading cause of hospitalization worldwide, especially in the elderly, and is associated with a high readmission rate and increased first year mortality. Fluid overload manifested by pulmonary congestion is seen in the majority of patients with ADHF and is believed to be the reason behind most admissions. ADHF is commonly treated with intravenous diuretics aimed to alleviate congestion and restore euvolemia. In fact, current European and American guidelines for heart failure (HF) consider relief of congestion as the first-line therapy in ADHF. Following the same theme of reducing fluid retention, historical approaches have recommended water and salt restriction as an essential non-pharmacological therapy in the management of symptomatic HF. This 'common sense' dietary practice was mainly based on experts' opinions and has been challenged by recent data suggesting that salt or fluid restriction has neutral outcomes in achieving clinical stability and improving signs and symptoms of HF.