Managing Fluid Balance

Shannon Donovan • 6 September 2023


Heart failure patients can find it tricky to manage a fluid balance due to the medications that are prescribed, being on fluid restrictions, some co-morbid conditions and having a GI illness. Diuretics are used to help rid the body of excess fluids to keep the heart from having to work hard pumping excess fluid around. But valsartan/sacubitril (Entresto), empaglifozin (Jardiance) or dapagliflozin (Farxiga) can increase the loss of more fluid, especially when taken together. Also heart failure patients are recommended to be on these drugs and others (i.e., Beta blockers, ace receptor inhibitors, angiotensin receptor inhibitors, calcium channel blockers, just to list a few) that can exaggerate the effect of the body’s response to loss of excess fluid or dehydration.

It is particularly important to prevent dehydration because being dehydrated means your heart works harder to pump blood. This can cause your heart to beat faster, cause an irregular heartbeat or even palpitations. In addition, dehydration makes your blood thicker and constricts blood vessel walls. This can cause high blood pressure and put strain on your heart. Also becoming dehydrated can lead to lower blood pressure, which may cause dizziness.

It is very importance to weight yourself daily, tracking and keeping a log of your morning “dry” weights (after first urination in the morning, before eating or drinking, and keeping the amount of clothing consistent when measuring weights from day-to-day). Call your provider if your weight goes up or down 2-3 pounds within 24 hours or 4-5 pounds within 7 days.

Also, remember having an illness that causes excess vomiting or diarrhea can affect fluid balance and cause dehydration from the loss of fluids. It is important to call your provider when you have this kind of illness, so adjustments can be made if necessary. These illnesses can also lead to electrolyte imbalances, along with dehydration, which can cause issues with arrhythmias.


Staying hydrated for a heart failure patient is not always easy, especially with a fluid restriction directed by your provider. A fluid restriction is used to help avoid overloading your heart as more fluid in your bloodstream which makes it harder for your heart to pump. A restriction may be from 1.5 to 2L (48-64 oz.) per 24 hours. If you are on a fluid restriction, keep in mind fluids such as sugary sodas and full-strength juices slow down the passage of water from the digestive system to the bloodstream. Certainly, do not rely on caffeinated beverages or alcohol for fluid because they can cause or intensify dehydration. Most of your hydration should come from water (do not drink sports drinks like Gatorade and PowerAde, unless instructed by your health care provider, because of the added sodium and sugar). If you are on a fluid restriction, record your fluid intake to check you are within your daily limit. This may need adjusting in warmer weather, discuss with your provider. You should also include in your record foods that contain a lot of water, like gravy, fruit (especially melons), yogurt, jelly, etc.

Other examples of fluids:

  • Sparkling water (no sodium or sugar added)
  • Milk
  • Soups and broths
  • Ice cream and sherbet
  • Popsicles
  • Frozen yogurt
  • Gelatin desserts (Jell-O)
  • Tea and coffee (limit caffeine)
  • Soft drinks (limit quantity, limit caffeine and sugar)


Thirst is a natural function of your body to help maintain fluid balance. The sensation of thirst is a phenomenon experienced in nearly half of heart failure patients. Part of the sensation of thirst has to do with the physiology of heart failure as blood traveling to the kidneys is reduced, hormone interactions occur, stimulating thirst. For this reason, it is especially important to maintain fluid and electrolyte, such as sodium, balanced with heart failure, as to not worsen or activate further these physiological mechanisms. The feeling of thirst then does not always mean take in more fluids. So, thirst can be caused by fluid restriction, which is part of self-care management for some heart failure patients.

If you feel thirsty, try chewing gum, a sugar-free mint, or pieces of frozen fruit (such as grapes or strawberries). You can also rinse your mouth with water but do not swallow it, sip water and do not gulp it, or add natural flavoring with some berries or fresh squeezed lemon juice to water or a small cup of ice chips. If your lips feel dry, try lip balm.

Tips to Control Thirst on a Fluid Restriction:

  • Use lip balm to keep your lips moist.
  • Chew gum
  • Suck on sugar-free hard candy
  • Suck on lemon or lime wedges
  • Have a breath mint (sugar free)
  • Eat chilled or frozen fruits like grapes or strawberries
  • Rinse your mouth or use oral swabs

Dehydration is different than being thirsty. You may be dehydrated if you have the following symptoms:

  • Fatigue
  • Shortness of breath
  • Weakness in your muscles
  • Urinating less frequently or in low volume
  • Dark urine
  • Headache
  • Dizziness that is persistent, not just with position changes
  • Dry mouth or skin
  • Rapid heart rate
  • Low blood pressure
  • Sudden weight drop (3-5 lbs in 2 days)
  • Lethargy
  • Fever

If you are having any of these symptoms and you think you might be dehydrated, contact your internal medicine/primary care doctor or your cardiologist office to report the symptoms you are having.   It also always important to let your heart failure specialist/cardiologist know when you have an illness with vomiting and diarrhea so they can help you adjust your medications appropriately to avoid severe dehydration.  



Marissa Burgermaster, PhD, MA,1 Rebecca Rudel, RD, MPH,2 and David Seres, MD, ScM, PNS, FASPEN (2020, July 17). Dietary Sodium Restriction for Heart Failure: A Systematic Review of Intervention Outcomes and Behavioral Determinants.


Sterns, R.H. (2020). Etiology, clinical manifestations, and diagnosis of volume depletion in adults.  Retrieved from Up to Date on 4.30.2020…