Elevated blood pressure is a common and powerful predisposing factor for stroke, coronary disease, cardiac failure and peripheral artery disease imposing a 2-3 fold increased risk of one or more of these atherosclerotic sequelae. The risk ratio imposed by hypertension is greatest for cardiac failure and stroke, but in Western countries coronary disease is the most common and lethal hazard. In hypertensive men and women respectively, 35% and 45% of myocardial infarctions are silent or unrecognized necessitating routine periodic ECG examination for its detection. Comparison of the impacts of systolic and diastolic blood pressure gives no indication of a greater impact of diastolic pressure and isolated systolic hypertension is distinctly hazardous. Over-reliance on diastolic pressure to assess risk can be misleading, particularly in advanced age. Attributable risk estimates suggest that 78% of hypertension in men and 65% in women is directly attributable to adiposity, making weight control of paramount importance for primary prevention of hypertension. The likelihood of development of cardiovascular disease in the hypertensive patient is greatly enhanced by the presence of metabolically-linked risk factors and already existent cardiovascular conditions. These influence the urgency and choice of therapy. Rational and efficient assessment of the hypertensive candidate for cardiovascular disease requires use of a cardiovascular risk profile evaluating the joint effect of multiple risk factors and effective treatment improves multivariate risk. (Hypertens Res 1995; 18: 181-196)