Management of hypertension and cardiovascular risk. Blood pressure reduction in hypertensive patients is a surrogate for the real therapeutic goal of reducing the risks consequent to hypertension. This surrogate is convenient but its use may have important therapeutic implications. Results of treatment with new antihypertensive agents, data from clinical trials, and insights into underlying mechanisms are reviewed. The overall success of antihypertensive therapy has been undeniable, but has reduced minimally the frequency of atherosclerosis and coronary events; metabolic disarray resulting from the agents used, especially thiazides and beta blockers, may have contributed to this. Electrolyte abnormalities predispose to malignant arrhythmias and sudden death during myocardial infarction. Left ventricular hypertrophy, a chief risk factor for coronary events, arrhythmias, and heart failure, responds selectively to antihypertensive agents. Similarly, progression of renal injury may be sensitive to the agents used. Obesity and hypertension frequently coexist. Evidence is growing that atherogenic abnormalities common in obese patients, such as insulin resistance, also occur in the nonobese patient and are sensitive to the antihypertensive agent selected. 