The pathophysiology of essential hypertension and its complications has been a focus of much research and clinical interest. More recent attention has been directed towards inflammation and endothelial dysfunction, especially since inflammation can promote endothelial dysfunction and the latter has been intimately related to thrombogenesis and atherogenesis. Hypertension is also associated with a prothrombotic or hypercoagulable state, and this may contribute to the observation that despite the blood vessels being exposed to high pressures in hypertension the common complications of the latter are paradoxically thrombotic rather than hemorrhagic – the so-called ‘thrombotic paradox of hypertension’ (or ‘Birmingham paradox’). Despite these thrombotic complications, the role of antithrombotic therapy for primary prevention in hypertension is less defined, unless the patient is at significant risk of cardiovascular events or has renal impairment. Antithrombotic therapy for secondary prevention in hypertension is recommended, but unanswered questions regarding the interactions between aspirin and angiotensin-converting enzyme inhibitors remain.