OBJECTIVE: Despite the existence of effective therapy, millions of Europeans have blood pressure (BP) above internationally agreed targets for control of cardiovascular risk. There is particular resistance to aggressive management of the elderly. We estimated the acute health-care costs resulting from failure to achieve BP targets in older adults in France, Germany, Italy, Sweden and the UK. METHODS: We constructed a burden of disease model to estimate the costs of uncontrolled hypertension in this group. Prevalence of uncontrolled hypertension was taken from the MONICA study and published surveys. The relationships between three cardiovascular (CV) events – symptomatic acute myocardial infarction (AMI), congestive heart failure (CHF) and stroke – and BP were estimated from a large prospective study (the HOT trial). Costs came from government sources and published studies. We estimated the acute medical costs of these events at current prevalence of uncontrolled hypertension and expected number of events and cost if BP were treated to target levels. Stochastic simulation was used to construct confidence intervals. RESULTS: Among adults older than 65 years in the five countries, an estimated 15.2m have BP above 160/95 mmHg and a further 12.9m have BP in the range 140/90–160/95 mmHg. The model estimated that 505,000 CV events (AMI–91,000; CHF–190,000, stroke–224,000) occur each year in those older than 65 in these countries, resulting in annual acute hospital costs of Euro2.3Bn (95% CI Euro2.04–2.53Bn). One hundred twenty eight thousand of these events (AMI–9,000; CHF–55,000, stroke–64,000) could be avoided if BP targets were met. The annual cost of these avoidable events was estimated to be Euro560m (95% CI Euro300-783m), representing 24.2% of the acute medical cost of these CV events in this population. CONCLUSION: Failing to implement existing guidelines for BP management in the elderly contributes substantially to the total human and economic burden of CV disease. Practical Design Issues