Distinct brain systems support afferent and efferent autonomic activity.

For decades, the Veterans Health Administration (VHA) has exemplified hypertension care, blending evidence-based treatment with system-wide implementation strategies that pushed blood pressure (BP) control rates to >75% at select facilities in the early 2000s. Yet, after US surveillance data signaled a decrease in population-level BP control starting in 2014, there has been scant evidence describing BP control rates among Veterans who newly start antihypertensive therapy, particularly with respect to the stricter targets recommended by contemporary clinical guidelines. Two major, sequential events may have impacted BP control in the VHA. First, the 2017 American College of Cardiology/American Heart Association (ACC/AHA) BP guideline lowered the threshold for antihypertensive medication initiation and intensification from systolic BP (SBP) ≥140 mm Hg or diastolic BP (DBP) ≥90 mm Hg to SBP/DBP of 130/80 mm Hg for US adults at cardiovascular risk. Second, the COVID-19 pandemic disrupted clinical care in 2020, reshaping how Americans received healthcare. While several studies reported modest reductions in BP control in the general population during these times, similar VHA studies have included mixed hypertensive populations (treated and untreated alike) or prevalent antihypertensive medication users, and without separately examining the impacts of each event on BP control among new treatment initiators. Clinical inertia, the failure to start or intensify treatment despite evidence of uncontrolled disease, occurs in 30–55% of hypertension-related visits and is a central barrier to achieving BP control nationwide. Factors contributing to inertia, such as pre-treatment BP level and reliance on monotherapy, may also influence medication adherence, further limiting treatment effectiveness. Understanding BP management in patients newly initiating therapy, who may be especially vulnerable to inertia during periods of change or care disruption, is particularly important because early treatment response strongly influences long-term BP outcomes and cardiovascular risk. Prior work has evaluated upstream gaps in rates of hypertension awareness, diagnosis, and treatment in the VA. To further inform the VA’s future efforts and policies to advance BP control, we sought to evaluate early management among Veterans newly initiating antihypertensive medications using a new-user study design. We evaluated differences in pre- and post-treatment BP levels and one-year BP control and medication adherence in three time periods (pre-guideline/pre-pandemic, post-guideline/pre-pandemic, and post-guideline/post-pandemic). Therefore, we conducted the following analysis to assess differences in pre- and post-treatment BP levels and one-year BP control and medication adherence among Veterans initiating treatment for hypertension in three time periods (pre-guideline/pre-pandemic, post-guideline/pre-pandemic, and post-guideline/post-pandemic). Therapeutic inertia encompasses both failure to initiate and failure to intensify therapy; this study focuses on post-initiation inertia by evaluating early management and outcomes during the first year after treatment start. By providing a current benchmark near the publication of the 2025 AHA/ACC BP Guideline, these findings aim to inform the VHA’s future efforts and policies to advance BP control for all Veterans.