Hypertension is one of the most common medical problems in industrialised societies and represents a major risk factor for cardiovascular morbidity and mortality. Most of the complications from hypertension occur in patients with mild hypertension in whom atherosclerotic disease, especially in coronary arteries, is more frequent.As recently suggested in European Society of Cardiology–European Society of Hypertension (ESC/ESH) Guidelines for Management of Hypertension, diagnostic procedures in patients with hypertension are aimed at the following: (i) establishing blood pressure levels (and consequently grade of hypertension); (ii) identifying possible secondary causes of hypertension according to rational algorithms; and (iii) evaluating the overall cardiovascular risk by identifying other risk factors, target organ damage and concomitant diseases or accompanying clinical conditions.Epidemiological data have shown a close relationship between atherosclerotic changes in the carotid artery (such as intima media thickness and plaques) and an increased risk of infarction and/or cerebrovascular disease. These observations have recently prompted increasing interest in investigating alterations in the carotid artery wall in patients with hypertension or in patients with other cardiovascular conditions.Measurements of the intima-media complex can also be used as relevant intermediate endpoints of antihypertensive treatment trials. In fact, it is important to establish the effectiveness of therapy administered by quantifying progression/regression of target organ damage using intermediate phenotypes of cardiovascular disease, and thus not only through the evaluation of blood pressure reduction.In this article, we briefly review the impact of the presence of vascular lesions on natural history and risk stratification in patients with hypertension, as well as the effects of therapeutic control of the vascular lesions and regression, in order to sustain systematic evaluation of the arterial tree in hypertension.