Management of Blood Pressure 191/91 mmHg in a Skilled Nursing Facility
This patient requires immediate blood pressure reassessment and initiation of oral antihypertensive therapy, not intravenous treatment, as this represents severe hypertension without evidence of acute end-organ damage (hypertensive urgency). 1
Immediate Assessment Steps
First, confirm the elevated reading with repeat measurements in both arms using proper technique, as a single severely elevated reading is insufficient for diagnosis. 1 This is critical because:
- Guidelines consistently define hypertensive urgency as BP >180/120 mmHg without end-organ damage 1, 2
- Your patient's reading of 191/91 mmHg meets the systolic threshold but the diastolic is below the typical urgency cutoff 1
- Repeat measurements rule out measurement error or white coat effect 1
Perform a focused evaluation for end-organ damage to distinguish between hypertensive urgency and emergency:
- Physical examination focusing on neurologic status, cardiac function, and respiratory distress 1
- Fundoscopic examination for papilledema or hemorrhages 1
- Renal panel (creatinine, BUN) 1
- Electrocardiogram 1
- Neuroimaging, echocardiogram, or chest CT only if symptoms suggest specific organ involvement 1
Treatment Algorithm
If No End-Organ Damage (Hypertensive Urgency)
Do NOT use intravenous medications. 1, 2, 3 Most guidelines recommend outpatient treatment with oral antihypertensives initiated within the week following presentation. 1
Initiate oral combination antihypertensive therapy immediately as first-line treatment for BP ≥140/90 mmHg:
- Preferred initial combination: RAS blocker (ACE inhibitor like lisinopril 10-20 mg daily OR ARB like losartan 50 mg daily) PLUS either a calcium channel blocker (amlodipine 5 mg daily) OR thiazide diuretic (chlorthalidone 12.5-25 mg daily) 1, 4, 5, 6
- This combination approach is recommended by the 2024 ESC guidelines as first-line for most hypertensive patients 1
Target blood pressure: <130/80 mmHg to be achieved within 3 months 1, 6
If End-Organ Damage Present (Hypertensive Emergency)
Transfer to hospital intensive care unit for intravenous therapy with titratable agents. 1, 2, 3
Recommended IV agents (in order of preference):
Avoid these agents:
- Sodium nitroprusside (extremely toxic) 2, 3
- Immediate-release nifedipine (unpredictable effects) 2, 3
- Hydralazine (second-line only) 1, 3
- Nitroglycerin (not first-line) 2, 3
Special Considerations for Skilled Nursing Facility Patients
Elderly patients may require individualized BP targets. While the general target is <130/80 mmHg for adults <65 years, patients ≥65 years should target SBP <130 mmHg with consideration of frailty, dementia, and multimorbidity. 1, 6
Common pitfalls to avoid:
- Do not treat asymptomatic elevated BP with IV medications - this represents clinician inertia and inappropriate escalation 1
- Do not delay treatment - only 16.8% of patients with BP ≥140/90 mmHg receive new antihypertensive medication, contributing to poor control rates 1
- Do not use monotherapy - combination therapy is more effective and recommended as first-line 1, 6
Follow-Up Protocol
Recheck blood pressure after 2 weeks of antihypertensive treatment. 7
If BP remains ≥160/100 mmHg despite treatment:
- Escalate to three-drug combination (RAS blocker + CCB + thiazide diuretic) 1, 7
- Consider resistant hypertension workup 1
For resistant hypertension (uncontrolled on 3 drugs):
- Add low-dose spironolactone 25 mg daily 1
- If spironolactone not tolerated: eplerenone, amiloride, or higher-dose thiazide 1
- Reinforce sodium restriction and lifestyle measures 1
Team-Based Care Approach
Implement multidisciplinary management to improve BP control rates:
- Pharmacist-led medication titration and monitoring (improves control rates by 53% vs usual care) 1
- Nurse-managed BP clinics for regular monitoring 1
- Home BP telemonitoring if available 1
- Health coaching for lifestyle modifications 1
This systematic approach has increased BP control rates from 54% to 84% in integrated health systems. 1