Insulin resistance, a common accompaniment of essential hypertension, increases cardiovascular risk both directly, and via its adverse effect on other cardiovascular risk factors. Decreasing insulin resistance by lifestyle modification including diet, weight loss, and physical exercise is an important component of therapy in all patients. With the exception of thiazide diuretics as monotherapy, the currently utilized classes of agent appear equally effective in lowering blood pressure in insulin resistant patients. Currently utilized agents do, however, differ substantially in their effect on insulin resistance and associated risk factors. Agents that diminish insulin resistance may have a rationale in treating insulin resistant patients with hypertension although a decisive recommendation about class of agent in this group of patients must await several prospective large scale trials currently underway. Lower intervention thresholds and lower therapeutic goals would appear to apply to hypertensive patients with insulin resistance especially in the presence of impaired glucose tolerance or overt diabetes mellitus.