OBJECTIVES: According to current guidelines for the primary prevention of cardiovascular disease (CVD), early risk stratification might be critical to planning appropriate management. This study was performed to explore how different methods stratify the risk of CVD and how the awareness of CVD risk impacts its management in hypertensive patient. METHODS: A prospective, multi-center observational study was conducted in hypertensive patients aged > 40 years in Korea. CVD risk was assessed using the clinical algorithm (the National Cholesterol Education Program-Adult Treatment Panel III guideline) and carotid ultrasound (CUS). Physicians’ CVD risk management patterns were assessed through chart review. Patients also completed a questionnaire before and 6months after CVD risk assessment to determine self-reported behavioral changes. RESULTS: Among 294 (male 65%,  61±8 years), 14,9, 77.8 and 7.3% patients were determined to have low, moderate and high CV risk by CUS and 49.0 and 51.0% patients were low and high risk by clinical algorithm, respectively. Among 273 patients classified as having low-to-moderate CV risk by the clinical algorithm, approximately half of patients (51%, 138/273) were redefined as high risk by CUS. For the high-risk comparing to the low-risk patients based on CUS, physicians set more lowered target goals for the management of hypertension (25.8 vs. 3.6% of physicians, P<0.001), LDL-cholesterol (51.6 vs. 23.6% of physicians, P<0.001) and more changed the intensities of anti-hypertensive agent (4.9 vs. 1.2% of physicians, P=0.047). Patients reported higher rates of smoking cessation, dietary changes (reduced dietary sodium), and increased medication compliance at 6month comparing to the baseline (P<0.05, respectively). CONCLUSIONS: This study shows that there is a significant difference in CVD risk level between clinical algorithm and CUS. However, proactive awareness of CV risk had major effects on physician and patient behaviors in CVD risk management.