Purpose of review: This review is intended to provide the background for a broad view of the influence of large-artery stiffness on the development of hypertension in aging, diabetes and end-stage renal disease. Recent findings: Arterial stiffness, particularly in aorta, is a major determinant of isolated systolic hypertension in the elderly. Studies have consistently shown that large-artery stiffness results in augmented amplitude of reflected pressure waves and their early return. This disturbed physiological phenomenon can alter the heart-vessel coupling and lead to increased cardiovascular risk. This review describes the structural, functional, environmental and genetic factors that influence arterial stiffness, wave reflection, and blood pressure. It also discusses non-invasive techniques to measure arterial stiffness and analyze arterial waveforms. The effects of various antihypertensive agents with respect to arterial stiffness and blood pressure reduction are examined. In addition, studies on non-pharmacologic interventions to modify large artery behavior are reviewed. Summary: Optimal clinical management of hypertension depends on better understanding of the contribution of vascular stiffness to hypertension. This information has significant implications for therapeutic decisions.