Background: Sodium restriction is an accepted nonpharmacological strategy for fluid management in heart failure. In an intensive care unit (ICU) setting, high sodium loads have been associated with avoidable derailment of fluid balance. The international guidelines recommend restricting the total sodium intake to <2,000 mg/day or <87 mmol/day for patients with heart failure. Previous studies in the ICU have shown a high median daily sodium administration (approximately 225 mmol/day); however, there is a paucity of data on patients with heart failure with reduced ejection fraction (HFrEF).
Methods: A retrospective observational cohort study was performed in an tertiary teaching hospital network over a 3-month period. Data on intravenous (IV) fluids, IV medicines, medicine diluents, line flushes, and oral/rectal medicines with known high sodium were obtained. The amount of sodium administered each day from these sources was calculated and compared with the current guidelines.
Results: A total of 116 patients were reviewed, with an even distribution of patients from cardiac (57 patients) and noncardiac units (59 patients). The median sodium administration was 5.2 mmol/day (IQR, 0.00–15.55). For cardiac versus noncardiac units, the medians were 3.74 mmol/day (IQR 0.00–11.45) and 7.0 mmol/day (IQR 0.00–18.99), respectively. The primary sources of sodium were IV fluids, line flushes, and oral or rectal medicines.
Conclusion: This study suggests that patients with HFrEF admitted to a tertiary hospital network are not receiving sodium greater than the current recommendations mentioned in the guidelines. A pharmacist’s review on the amount of sodium administered might be a clinical pharmacy safety initiative to ensure that patients with HFrEF do not receive excessive sodium from inadvertent sources.

Background: An Australian consensus statement on the pharmacological prevention and management of heart failure, released in August 2022, recommended initiation of four medications for treating heart failure with reduced ejection fraction (HFrEF): angiotensin- converting enzyme inhibitors or angiotensin receptor-neprilysin inhibitors, heart failure beta blockers, mineralocorticoid receptor antagonists and sodium glucose co-transporter 2 inhibitors. These four medications are classified as the guideline-directed medical therapy (GDMT). Intravenous administration of ferric carboxymaltose (IFC) in the hospital, following an episode of acute heart failure in patients with iron deficiency and an ejection fraction of less than 50% was also recommended to reduce heart failure related hospital admissions as demonstrated in the AFFIRM-AHF trial.
Methods: A study conducted a retrospective audit of patients with HFrEF discharged by the Cardiology and the General Medicine teams of a tertiary hospital between two time periods, October to December 2021, and October to December 2022. Information including patient demographics, medication allergies and iron studies was collected. Discharge medication lists were extracted, reviewed for GDMT prescription and audited to check the accuracy of heart failure medication documentation. SPSS v29 was used to perform the statistical analysis.
Results: A greater proportion of patients were discharged on optimal GDMT across both study periods by the Cardiology department compared with the General Medicine department (37% versus 4% respectively, p<0.001). More accurate recording of heart failure medications in discharge summaries was performed by the Cardiology department compared with the General Medicine department (82% versus 68% respectively, p=0.015). Lastly, eligible Cardiology patients were more likely to receive IFC compared with General Medicine patients (71% versus 28%, p=0.003).
Conclusion: Overall, the audits performed in this study demonstrated that improvements in HFrEF GDMT prescribing adherence, documentation accuracy and IFC administration are warranted since the current practice is suboptimal, particular in General Medicine teams. The barriers to GDMT adherence at the prescribers’ end will require further examination and the appropriate quality improvement tools need to be implemented to ensure that all patients with HFrEF have equal access to optimal healthcare.