How to manage a hypertensive patient with normal blood pressure (130/90) who is experiencing intermittent dizziness and disrupted yawning?

Management of Blood Pressure 130/90 with Intermittent Dizziness and Disrupted Yawning

This blood pressure of 130/90 mmHg does not meet the threshold for hypertension diagnosis and does not require antihypertensive medication intensification—the focus should be on investigating the dizziness and yawning symptoms, which are likely unrelated to blood pressure control. 1

Blood Pressure Classification and Treatment Threshold

• A blood pressure of 130/90 mmHg falls into the "elevated BP" category (systolic 120-139 mmHg or diastolic 70-89 mmHg), not hypertension, according to the 2024 ESC guidelines. 1
• Hypertension is defined as sustained blood pressure ≥140/90 mmHg, which this patient does not meet. 1
• For patients with elevated BP (130/90 mmHg) without high-risk conditions (established CVD, diabetes, CKD, familial hypercholesterolemia, or hypertension-mediated organ damage), lifestyle measures are recommended rather than pharmacological treatment. 1

Symptom Evaluation Priority

The intermittent dizziness and disrupted yawning warrant investigation for causes other than hypertension:

• Orthostatic hypotension should be evaluated first—measure blood pressure supine and after 1-3 minutes of standing to detect drops ≥20 mmHg systolic or ≥10 mmHg diastolic, which could explain dizziness. 1
• If the patient is already on antihypertensive medications, these symptoms may indicate overtreatment or symptomatic orthostatic hypotension, which is specifically mentioned as an exception requiring careful management in the ESC guidelines. 1
• Disrupted yawning is not a typical manifestation of hypertension or hypotension and may suggest neurological, metabolic, or medication-related causes requiring separate evaluation.

Management Algorithm for This Specific Scenario

If Patient is NOT Currently on Antihypertensive Medications:

• No pharmacological treatment is indicated for BP 130/90 mmHg without high-risk conditions or 10-year CVD risk ≥10%. 1
• Implement lifestyle modifications: sodium restriction to <2g/day, weight management (target BMI 20-25 kg/m²), regular aerobic exercise, and alcohol limitation to <100g/week. 1
• Confirm blood pressure with out-of-office measurements (home BP monitoring or 24-hour ambulatory monitoring) to rule out white-coat effect. 1
• Investigate dizziness: check for orthostatic hypotension, vestibular disorders, anemia, hypoglycemia, or cardiac arrhythmias.

If Patient IS Currently on Antihypertensive Medications:

• Consider down-titration or discontinuation of medications if BP is consistently 130/90 mmHg and the patient has symptomatic orthostatic hypotension or moderate-to-severe frailty. 1
• The ESC guidelines specifically recommend considering exceptions to standard treatment for patients with symptomatic orthostatic hypotension. 1
• Measure orthostatic vital signs to confirm if dizziness correlates with positional blood pressure changes.
• If orthostatic hypotension is confirmed, reduce or eliminate medications contributing to hypotension, particularly diuretics, alpha-blockers, or centrally acting agents.

Critical Pitfalls to Avoid

• Do not intensify antihypertensive therapy based solely on a BP of 130/90 mmHg—this does not meet the treatment threshold for hypertension. 1
• Do not dismiss the dizziness as "just hypertension"—at 130/90 mmHg, the BP is not high enough to cause hypertensive symptoms, and dizziness more likely indicates orthostatic hypotension or another etiology.
• Do not start pharmacological treatment without confirming sustained hypertension (≥140/90 mmHg) with out-of-office measurements. 1
• If the patient is elderly (≥85 years) or has moderate-to-severe frailty, even more conservative BP targets may be appropriate, and symptomatic hypotension should be avoided. 1

Follow-up Recommendations

• Recheck blood pressure in 3-6 months if lifestyle modifications are implemented. 1
• Perform cardiovascular risk stratification (10-year CVD risk calculation) to determine if the patient has risk ≥10%, which would warrant pharmacological treatment even with elevated BP. 1
• If 10-year CVD risk is 5-10% with risk modifiers (family history, chronic inflammation, metabolic syndrome), or if risk is ≥10%, then pharmacological treatment should be initiated despite BP being <140/90 mmHg. 1
• Complete workup for dizziness including orthostatic vital signs, complete blood count, metabolic panel, ECG, and consideration of vestibular testing or neurological evaluation as clinically indicated.