Thirst in heart failure: the forgotten symptom in fluid restriction

This invited commentary refers to ‘Exploring the experience and management of thirst in patients with heart failure: a qualitative study from patients and nurses’, by Y. Zheng et al., https://doi.org/10.1093/eurjcn/zvaf253. Heart failure (HF) remains one of the most symptom-burdensome chronic cardiovascular conditions, affecting more than 64 million people worldwide.1 While dyspnoea, fatigue, and oedema have traditionally dominated clinical attention, thirst experienced by patients with HF is increasingly recognized as a major determinant of quality of life, treatment adherence, and clinical outcomes including hospital readmissions.2 Thirst, a multidimensional symptom with physical and psychological attributes, remains surprisingly underexplored despite its frequent occurrence and profound impact on patients’ daily lives,3 with up to 75% of patients reporting moderate to severe thirst but only 13.4% being asked about it by healthcare providers.2,4 In their qualitative study, Zheng and colleagues4 provide important insights into the experience and management of thirst from the perspectives of both patients with HF and the nurses caring for them. Their findings highlight thirst not merely as a physiological sensation but as a persistent and distressing symptom shaped by neurohormonal activation, pharmacologic therapy, and the behavioural demands of HF self-management, particularly fluid restriction. More broadly, the work by Zheng and colleagues4 contributes to the growing field of HF symptom science, which emphasizes the multidimensional and patient-centred nature of symptom experiences and implications for nursing practice A recent quantitative study5 documented factors associated with thirst, including salt restriction, medications such as renin angiotensin aldosterone inhibitors, statins and antidepressants, and gender, with other investigators reporting fluid restriction, depression, age, body mass index and diuretics as correlates of thirst.2 Understanding how symptoms interact with treatment recommendations and daily self-management behaviours is essential for designing care strategies that are both clinically effective and acceptable to patients. The paradox of thirst in HF may become even more pronounced as contemporary evidence increasingly questions the routine use of strict fluid restriction.6 Nurses need guidance on how to manage thirst. Historically, strict fluid restriction has been widely recommended to prevent fluid overload and worsening congestion. However, recent consensus statements have challenged the universal application of this approach given the limited and low-quality evidence. Contemporary guidance suggests that routine fluid restriction may not be necessary for all patients with HF and should instead be considered in selected situations, such as severe congestion or dilutional hyponatraemia.7 Rather than applying a uniform restriction, a more individualized approach to fluid intake is increasingly encouraged, guided by thirst perception and clinical status.7 Similarly, the evidence for the benefit of sodium restriction is of low quality, and is recommended for stage C HF to reduce congestive symptoms.7 This evolving perspective has important implications for symptom management. Strict fluid restriction has been associated with poor quality of life, persistent thirst, xerostomia, and reduced adherence to dietary recommendations. For many patients, thirst becomes one of the most distressing consequences of HF self-management. On the other hand, salt restriction is negatively associated with thirst intensity.5 Therefore for patients who complain of thirst, limiting salt intake can be used to help manage this symptom, along with encouraging consumption of juicy fruits as appropriate to quench their thirst. Attention also needs to be paid to the medications prescribed to the patients that may intensify this unpleasant symptom. From a nursing perspective, these findings reinforce the importance of balancing congestion prevention with symptom relief and patient-centred care. Nurses play a central role in HF education, symptom assessment, and self-care support. As such, they are uniquely positioned to identify and address thirst as part of routine symptom evaluation. Incorporating structured assessment of thirst into HF care and educating patients about practical strategies to alleviate thirst may help mitigate symptom burden while maintaining safe fluid balance. Assessment measures of thirst are brief and easy to administer in the clinical setting; thus, monitoring thirst is recommended as a standard of care.2,6 By bringing attention to this often-overlooked symptom and highlighting the perspectives of both patients and nurses, Zheng and colleagues4 provide a valuable reminder that effective HF management must extend beyond physiological stabilization to encompass the lived experiences of those navigating the daily realities of the disease. Their findings suggest the need for more research on thirst to inform practice through the development of interventions that target the physiological and psychological aspects of the symptom and its risk factors. Assessment and management of thirst ought to be addressed in evidence-based clinical guidelines. SN and AM equally contributed to the conceptualization, investigation, writing the draft, review, and editing. Samar Noureddine [Conceptualization, Investigation, Writing—original draft, Writing—review & editing (equal)], and Angela Massouh [Conceptualization, Investigation, Writing—original draft, Writing—review & editing (equal)] This work did not receive any funding. This commentary does not contain new data.