Physical exercise is known to lower blood pressure and reduce cardiovascular risk through a wide range of mechanisms. Nevertheless, hypertension is the most prevalent cardiovascular disease among athletes and physically active subjects. This article reviews the state of the art in practical approaches to this issue, focusing on special aspects a physician should take into account when diagnosing hypertension, such as screening of secondary causes, assessment of global cardiovascular risk and target organ damage and, in addition, the treatment choice in athletes.