Essential hypertension is associated with large and small vascular remodeling that impacts cardiovascular prognosis. Longitudinal follow-up of hypertensive patients has shown that large arterial stiffness decreases partly independently of blood pressure reduction, suggesting specific pharmacological effects of antihypertensive therapy. Inhibitors of the renin-angiotensin-aldosterone system are among the agents that have been shown to affect vascular remodeling to a greater degree. Lifestyle modifications, including exercise and weight reduction, also improve large and small vascular remodeling. New antihypertensive drugs, including neprilysin inhibitors associated with an angiotensin receptor blocker, aldosterone synthase inhibitors and new devices such as renal denervation and baroreceptor stimulation, may exert beneficial effects on vascular remodeling and are currently under evaluation.