Heart failure - fluids and diuretics

When you have heart failure, your heart does not pump out enough blood. This causes fluids to build up in your body. If you consume too much sodium, this can lead to fluid retention. You may get symptoms such as swelling, weight gain, and shortness of breath. Limiting how much salt (sodium) you take in can help prevent these symptoms. Inadvertently taking in too much sodium, or taking a medicine that causes your body to retain sodium (such as NSAIDs like ibuprofen and naproxen) may cause your heart failure to get worse.

Your family members can help you take care of yourself. They can keep an eye on how much sodium you consume. They can make sure you are taking your medicines the right way and avoid harmful medicines. And they can learn to recognize your symptoms early.

Your health care provider may ask you to limit your daily sodium intake to 1500 to 2300 mg per day. Your provider will monitor the level of sodium in your blood and may advise you to modify what fluids or how much fluid you consume.

Remember, some foods, such as soups and preserved foods contain sodium.

Eating too much salt can make more fluid stay in your body. Many foods contain "hidden salt," including prepared, canned and frozen foods. Learn how to eat a low-salt diet.

Your provider may recommend that you meet with a dietitian to help you have the best diet for you.

Diuretics help your body get rid of extra fluid. They are often called "water pills." There are many types of diuretics. Some are taken 1 time a day. Others are taken 2 times a day. The three common types are:

• Thiazides: Chlorothiazide (Diuril), chlorthalidone (Hygroton), indapamide (Lozol), hydrochlorothiazide (Esidrix, HydroDiuril), and metolazone (Mykrox, Zaroxolyn)
• Loop diuretics: Bumetanide (Bumex), furosemide (Lasix), and torsemide (Demadex)
• Potassium-sparing agents: Amiloride (Midamor), eplerenone (Inspra), spironolactone (Aldactone), and triamterene (Dyrenium)

There are also diuretic pills that contain a combination of two of the medicines above.

When you are taking diuretics, you will need to have regular checkups so that your provider can check your blood potassium levels and monitor how your kidneys are working.

Diuretics make you urinate more often. Try not to take them at night before you go to bed. Take them at the same time every day.

Common side effects of diuretics are:

• Fatigue, muscle cramps, or weakness from low potassium levels
• Dizziness or lightheadedness
• Numbness or tingling
• Heart palpitations, or a "fluttery" heartbeat
• Gout
• Depression
• Irritability
• Urinary incontinence (not being able to hold your urine)
• Loss of sex drive (from potassium-sparing diuretics), or inability to have an erection
• Hair growth, menstrual changes, and a deepening voice in women (from some potassium-sparing diuretics)
• Breast swelling in men or breast tenderness in women (from some potassium-sparing diuretics)
• Allergic reactions -- if you are allergic to sulfa drugs, you should not use thiazides

Be sure to take your diuretic the way you have been told.

You will get to know what weight is right for you. Weighing yourself will help you know if there is too much fluid in your body. You might also find that your clothes and shoes are feeling tighter than normal when there is too much fluid in your body.

Weigh yourself every morning on the same scale when you get up -- before you eat and after you use the bathroom. Make sure you are wearing similar clothing each time you weigh yourself. Write down your weight every day on a chart so that you can keep track of it.

Contact your provider if your weight goes up by more than 2 to 3 pounds (1 to 1.5 kilograms, kg) in a day or 5 pounds (2 kg) in a week. Also contact your provider if you lose a lot of weight.

Contact your provider if:

• You are tired or weak.
• You feel short of breath when you are active or when you are at rest.
• You feel short of breath when you lie down, or an hour or two after falling asleep.
• You are wheezing and having trouble breathing.
• You have a cough that does not go away. It may be dry and hacking, or it may sound wet and bring up pink, foamy spit.
• You have swelling in your feet, ankles, or legs.
• You have to urinate a lot, particularly at night.
• You have gained or lost weight.
• You have pain and tenderness in your belly.
• You have symptoms that you think might be from your medicines.
• Your pulse, or heartbeat, gets very slow or very fast, or it is not steady.

HF - fluids and diuretics; CHF - ICD discharge; Cardiomyopathy - ICD discharge

Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation. 2020;141(16):e774. PMID: 30879355 pubmed.ncbi.nlm.nih.gov/30879355/.

Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. Epub 2022 Apr 1. Erratum in: Circulation. 2022 May 3;145(18):e1033. Erratum in: Circulation. 2022;146(13):e185. Erratum in: Circulation. 2023;147(14):e674. PMID: 35363499 pubmed.ncbi.nlm.nih.gov/35363499/.

Lam CSP, Shah SJ, Solomon SD. Heart failure with preserved and mildly reduced ejection fraction. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 51.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 50.

Updated by: Michael A. Chen, MD, PhD, Associate Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.