Hypertension increases cardiovascular morbidity and mortality two- to fourfold. The chief hazards are now atherosclerosis and coronary disease. Risk is proportional to the degree of systolic or diastolic blood pressure elevation at any age, in either sex. More than the character of blood pressure elevation, commonly associated risk factors markedly influence the hazard. The risk of coronary heart disease is concentrated in hypertensive patients with a high total/high-density lipoprotein (HDL)-cholesterol ratio, impaired glucose tolerance, high fibrinogen, electrocardiographic (ECG) abnormalities, and who are cigarette smokers. Evidence of organ involvement such as left ventricular function are hallmarks of impending cardiovascular sequelae. Electrocardiogram-left ventricular hypertrophy (ECG-LVH) behaves like myocardial infarction in its clinical course, predisposing at the same rate to sudden death, infarction, cardiac failure, and stroke. Consideration of cardiovascular risk factors is required to evaluate properly the need for treatment, select the best treatment, set goals, and determine the efficacy of treatment. Awaiting evidence of organ involvement is dangerous since the first such evidence is often a sudden death, stroke, or myocardial infarction. Optimal treatment must improve the composite risk profile as well as lower the blood pressure.