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Invited Commentary |

Counterintuitive Evidence Concerning Salt and Water Restriction in Acute Decompensated Heart Failure Patients:  Comment on “Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure”

Melvin D. Cheitlin, MD
JAMA Intern Med. 2013;173(12):1064-1066. doi:10.1001/jamainternmed.2013.789.
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Fluid retention manifested by peripheral edema, fluid in the lungs, and ascites has been recognized as a sign of congestive heart failure from earliest times. In fact, in 1775, Withering,1 when describing the effects of the foxglove on patients with “dropsy,” believed that the major action of the drug was as a diuretic. Our present understanding of the pathophysiology of heart failure has evolved through the hemodynamic stage that focused on the heart as the primary cause with secondary effects on the kidney, where inotropic agents and diuretics were the mainstay of therapy to the neurohormonal stage. Here, activation of the sympathetic nervous system, the renin-angiotensin-aldosterone system, and vasopressin is recognized as increasing sodium and water retention, which elevates the intravascular volume and returns stroke volume and cardiac output to normal. Along with these temporary measures supporting the circulation come maladaptive consequences involving vasoconstriction, decreased renal blood flow, and sodium and water retention. Later effects are ventricular remodeling, loss of myocardial cells, and decreasing ventricular function. To counter these effects, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone, and vasopressin antagonists have become the modern optimal medical therapy for congestive heart failure.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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