This paper briefly reviews recent evidence concerning the relationship between hypertension and alterations in glucose and lipid metabolism and renal and cardiac damage. It is now clear that high blood pressure is frequently associated with insulin resistance and dyslipidaemia. This suggests a possible pathogenetic link between hypertension and deranged metabolism. It also suggests, however, that the hypertensive patient is likely to have other cardiovascular risk factors in addition to hypertension. It is also clear that lowering blood pressure may not only reduce the overall cardiovascular risk but may be specifically nephro- and cardioprotective. However, it is difficult to assess the effect of antihypertensive treatment in these areas, because there are no simple and sensitive measures of the progression of renal disease, and antihypertensive therapy does not provide consistent protection against coronary heart disease. Furthermore, the degree of protection obtained is less than would be expected on the basis of epidemiological evidence. Further trials are needed to fully resolve these issues.