Reduce Furosemide First in Euvolemic Mild Aortic Stenosis
In a euvolemic patient with mild aortic stenosis on telmisartan 80mg and furosemide 80mg, you should reduce or discontinue the furosemide, as diuretics should be used sparingly in aortic stenosis and only to maintain euvolemia, while the telmisartan (an ARB) should be continued as it is the preferred antihypertensive agent in this condition. 1, 2, 3
Rationale for Reducing Furosemide
Diuretics should only be used to achieve and maintain euvolemia in aortic stenosis—once the patient is euvolemic (as yours is), the dose should be reduced to the minimum necessary or discontinued entirely 1, 3
The American College of Cardiology specifically warns that diuretics should be used sparingly in patients with small left ventricular chamber dimensions, which is common in aortic stenosis due to concentric hypertrophy 1, 2
Excessive diuresis can lead to critical reduction in preload, causing worsening hypotension and compromised cardiac output across the stenotic valve—a particular concern in aortic stenosis where patients are preload-dependent 2, 3
High-dose loop diuretics (≥80mg furosemide) are associated with increased mortality, electrolyte disturbances, and neuroendocrine activation in heart failure patients 4
Why Telmisartan Should Be Continued
ACE inhibitors and ARBs (like telmisartan) are the preferred first-line antihypertensive agents in aortic stenosis due to their beneficial effects on left ventricular fibrosis, blood pressure control, dyspnea reduction, and improved effort tolerance 1, 2, 5
The 2017 ACC/AHA guidelines give a Class I recommendation for treating hypertension in aortic stenosis patients, with RAS blockade being advantageous over other agents 1
Recent evidence shows that RAS inhibition may actually retard progression of valvular stenosis and improve left ventricular remodeling in aortic stenosis 5
Telmisartan 80mg is an appropriate therapeutic dose for hypertension management and should not be reduced unless the patient develops hypotension or other adverse effects 6
Practical Management Approach
Reduce furosemide gradually (e.g., decrease to 40mg daily, then 20mg, then discontinue if patient remains euvolemic) while monitoring for signs of fluid retention 1, 3
Monitor closely for recurrent congestion: daily weights, symptoms of dyspnea, peripheral edema, and orthopnea 1, 3
Continue telmisartan 80mg and monitor blood pressure to ensure adequate control (target systolic 130-139 mmHg) 7
Check renal function and electrolytes 1-2 weeks after any diuretic dose reduction, as the combination of ARB and diuretic can affect kidney function 1, 8
Important Caveats
If the patient develops signs of fluid retention after furosemide reduction (weight gain >2kg, new edema, dyspnea), the diuretic should be restarted at the minimum effective dose 1, 3
Avoid excessive blood pressure lowering—start antihypertensives at low doses and titrate gradually in aortic stenosis to prevent hypotension 1, 2
The combination of telmisartan and furosemide can lead to severe hypotension and deterioration in renal function, so close monitoring is essential when adjusting either medication 8
Consider cardiology consultation for ongoing management, as the ACC/AHA guidelines recommend co-management with a cardiologist for patients with moderate or severe aortic stenosis (though your patient has mild disease) 1