What is the best course of action for a patient with hypertension, currently on telmisartan (Angiotensin II receptor antagonist) and amlodipine (Calcium channel blocker) (40/5), who experienced a single episode of lightheadedness without loss of consciousness, with a current blood pressure of mild hypertension and a random blood sugar of impaired fasting glucose?

Management of Hypertensive Patient with Single Episode of Giddiness

For a hypertensive patient on telmisartan/amlodipine (40/5) with a single episode of giddiness, current BP of 150/80, and normal blood sugar, optimization of antihypertensive medication is recommended rather than immediate neuroimaging studies.

Assessment of Current Situation

• The patient presents with a single episode of giddiness (lightheadedness) without loss of consciousness, which is a common symptom in patients with hypertension and may be related to blood pressure fluctuations 1
• Current BP is 150/80 mmHg, indicating suboptimal blood pressure control despite being on combination therapy with telmisartan 40 mg and amlodipine 5 mg 1
• Random blood sugar of 114 mg/dL is within normal limits, ruling out hypoglycemia as a cause of giddiness 1
• No murmurs on examination suggests absence of significant valvular heart disease 1
• No recurrence of giddiness in the past month indicates this was likely an isolated episode 1

Management Recommendations

Optimize Blood Pressure Control

• The current BP of 150/80 mmHg is above the recommended target of 120-129 mmHg systolic as per the 2024 ESC guidelines 1
• Consider increasing the dose of current medications or adding a third agent:
  • Increase telmisartan to 80 mg (maximum effective dose) as this provides greater BP reduction (12-13/7-8 mmHg) compared to 40 mg (9-13/6-8 mmHg) 2
  • Consider increasing amlodipine to 10 mg if tolerated 3, 4
  • If BP remains uncontrolled after dose optimization, add a thiazide/thiazide-like diuretic as a third agent, preferably in a single-pill combination to improve adherence 1

Diagnostic Workup

• Routine neuroimaging (CT head or echocardiogram) is not indicated for a single episode of giddiness without loss of consciousness or other neurological symptoms 1
• Consider ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to assess for:
  • Blood pressure variability throughout the day 1
  • Orthostatic hypotension which can cause giddiness, especially in patients on antihypertensive medications 1
• Basic laboratory tests to rule out electrolyte abnormalities or renal dysfunction that might contribute to symptoms 1

Lifestyle Modifications

• Reinforce importance of lifestyle measures to help achieve better BP control 1:
  • Sodium restriction (especially important in resistant hypertension) 1
  • Regular physical activity (150 minutes/week of moderate-intensity aerobic exercise) 1
  • Weight management targeting BMI 20-25 kg/m² 1
  • Limiting alcohol consumption (preferably avoiding it completely) 1
  • Reducing sugar consumption, particularly sugar-sweetened beverages 1

When to Consider Advanced Imaging

Neuroimaging (CT/MRI head) and/or echocardiogram would be indicated in the following scenarios 1:

• Recurrent episodes of giddiness or syncope
• Giddiness accompanied by focal neurological deficits
• Presence of cardiac symptoms or murmurs
• Severe, sudden-onset headache
• BP ≥180/120 mmHg with symptoms suggesting end-organ damage
• Signs of hypertensive emergency (visual disturbances, confusion, chest pain)

Follow-up Plan

• Schedule follow-up within 2-4 weeks to assess response to medication adjustment 1
• Educate patient about warning signs that would warrant immediate medical attention (severe headache, visual changes, chest pain, neurological deficits) 1
• Consider home BP monitoring to track response to treatment and detect any significant fluctuations 1

Conclusion

The single episode of giddiness without loss of consciousness in this hypertensive patient with suboptimal BP control most likely represents a benign event related to BP fluctuations. The focus should be on optimizing antihypertensive therapy to achieve target BP of 120-129 mmHg systolic rather than pursuing extensive diagnostic testing at this time 1.