Hypertension is a major global economic burden. Blood pressure management remains one of the most cost-effective methods of cardiovascular risk factor reduction. However, current hypertension management strategies remain sub-optimal and blood pressure remains poorly controlled in a high proportion of patients. Conventional economic studies in well controlled clinical trial settings have not adequately assessed factors such as non-compliance, switching and discontinuation of treatment which have an important impact on the costs of antihypertensive therapy in actual clinical practice. Furthermore, most conventional, randomized clinical studies may not fully reveal long-term benefits (e.g reductions in end-organ damage) which may be associated with newer therapeutic strategies. First-line use of rational, low-dose combination therapy can offer important advantages in terms of improved efficacy, tolerability and compliance, with reduced end-organ damage compared with conventional monotherapy. For newer hypertension management strategies, comprehensive pharmacoeconomic studies are needed which consider all of these important factors. Early economic analyses which failed to consider some of these newer issues should not hinder the more widespread use of novel strategies, including first-line low-dose combination therapy.