Angiotensin receptor blocker associated worsening of iron deficiency anemia precipitating high output heart failure in an elderly patient

Anemia is a common comorbidity in patients with cardiovascular disease and may contribute to heart failure. Angiotensin receptor blockers (ARBs), through inhibition of the renin-angiotensin–aldosterone system (RAAS), may suppress erythropoietin production and erythropoiesis. We report the case of a 67-year-old female with ischemic heart disease and hypertension on long-term telmisartan therapy who presented with breathlessness and bilateral pedal edema. Investigations revealed severe microcytic anemia (hemoglobin: 6.1 g/dL) with iron deficiency. Imaging showed cardiomegaly with bilateral pleural effusion, and the patient developed high-output heart failure with type II respiratory failure. ARB therapy was discontinued, and the patient was managed with blood transfusion and diuretics, resulting in clinical improvement and hemoglobin increase to 10.6 g/dL. This case highlights the potential contribution of RAAS blockade to worsening anemia and subsequent cardiac decompensation.