Background: Residual cardiovascular risk (RCVR) is an emerging issue in the clinical and therapeutic management of patients affected by hypertension. In fact, a number of clinical studies showed that even in case of optimal blood pressure (BP) control, the hypertensive patients still carry a sizeable increase in the CV risk as compared to normotensive individuals.Methods: We will review the clinical evidence about the determinants and the impact of RCVR on hypertension, with a specific focus on the progression of vascular damage. Results: The presence of RCVR in hypertensive patients is a significant phenomenon which challenges our clinical effort far beyond the reaching of BP targets. Although major determinants of RCVR are still undefined, there is a clear indication about the importance of an early and sustained control of BP values, so as to prevent the onset of target organ damage. In fact, our data and findings from the literature indicate that the "pseudo-normalization" of BP is not sufficient to abolish the risk of pro-atherogenic remodeling of arterial vessels. Conclusion: Additional studies are needed to establish whether the intervention on specific BP profiles and inflammatory mechanisms can have some clinical relevance in the management of RCVR. In the meanwhile, the precise phenotyping of the CV risk profile of each patient, coupled with a tailored pharmacological approach, represents the most effective strategy to hinder the progression of vascular damage and reduce the RCVR.