Hypertension is part of a disease continuum that can begin with vascular or endothelial dysfunction and progress to elevated blood pressure and target-organ damage (Figure 2). We now know that the hypertension paradigm is much more complicated than previously thought and can be a two-way street. Therefore, evaluation of arterial compliance can be important in the screening of patients at risk for hypertension and other cardiovascular diseases. Measurement of the compliance of both large and small vessels is now possible by several noninvasive methods, including impedance plethysmographic studies and sphygmomanometric measurements, ultrasound, oscillometric recognition of the cuff signal pattern, pulse contour analysis, and cuff sphygmomanometric studies. Evaluation of arterial compliance could allow early detection of vascular dysfunction and initiation of therapy to impede the process of vascular remodeling; the Treatment in Obese Patients With Hypertension substudy 34 is designed to address this possibility. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends either a diuretic or a b-blocker as initial therapy for hypertension. However, the report also suggests that certain complications commonly associated with this disease should prompt selection of alternative therapies, including a-blockers, calcium antagonists, and ACE inhibitors. Studies suggest that arterial stiffness is another important consideration in the selection of antihypertensive therapy and that it should be added to the list of comorbid conditions that influence treatment selection. Therapy with agents that can increase compliance and inhibit or reverse vascular remodeling has the potential to combat vascular dysfunction even before blood pressure is elevated. A formal csot-efficacy analysis of the use of therapy before blood pressure is elevated has not been performed, but therapy may be cost-effective in terms of cardiovascular events averted.