A recent meta-analysis of hypertension treatment trials demonstrated a marked reduction in the incidence of cerebrovascular disease, but a less pronounced reduction in coronary heart disease. Treatment consisted mainly of diuretics and β-blockers, and this paper discusses the possible influences of their metabolic side effects on coronary risk factors compared with newer agents: angiotensin-converting enzyme (ACE) inhibitors, selective α<sub>1</sub>-adrenoceptor inhibitors and calcium channel blockers. Several studies are underway to compare the effect of these compounds with diuretics and β-blockers with respect to long-term cardiovascular morbidity and mortality. Until the results of these studies are available, young patients (i.e. < 60-65 years) at high risk of coronary heart disease, especially patients with the insulin resistance syndrome or diabetes mellitus, should in our opinion be treated with ACE-inhibitors, selective α<sub>1</sub>-adrenoceptor inhibitors or calcium channel blockers.