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In the Danish population-based Lolland-Falster Health Study (LOFUS), conducted in a socioeconomically disadvantaged area with marked regional health inequalities, we recently identified a hypertension prevalence of 45%. A more detailed understanding of recognition, control, and treatment of hypertension in this setting may help improve interventions to reduce hypertension-related cardiovascular disease. This was a cross-sectional study including participants with hypertension identified in LOFUS using data from clinical examinations and questionnaires. Recognition was assessed by a registered diagnosis or self-reported hypertension and factors associated with recognition status were analyzed. Cardiovascular risk stratification was applied to individuals with unrecognized hypertension to determine treatment indication. Blood pressure (BP) control and antihypertensive treatment patterns were evaluated among participants with recognized hypertension. Among 7329 participants with hypertension, 39% were unrecognized. Individuals with unrecognized hypertension were younger, had higher educational attainment and fewer comorbidities than those with recognized hypertension. Larger household size was associated with higher odds of unrecognition. Two-thirds of individuals with unrecognized hypertension were classified as having high 10-year cardiovascular risk and met criteria for antihypertensive treatment. Among participants with recognized hypertension, 51% had uncontrolled BP despite >50% receiving ≥2 antihypertensive agents. The group with uncontrolled BP had fewer comorbidities than those with controlled BP. In this rural cohort with a high prevalence of hypertension, a large proportion remained unrecognized despite elevated cardiovascular risk, and among individuals with recognized hypertension, treatment targets were often not achieved. These findings indicate a substantial unmet need for improved recognition and management of hypertension, with important implications for public health.