Left ventricular hypertrophy is both a major adaptive response to chronic pressure overload and an important risk factor in patients with hypertension. It is now well appreciated that structural changes in the myocardium are mediated not only by the mechanical stress of pressure overload but also by various neurohormonal substances that exert trophic effects on myocytes and non-myocytes in the heart. Both earlier recognition and improved understanding of cardiac hypertrophy may lead to more effective therapeutic strategies for hypertension. This review focuses on the underlying mechanisms in hypertensive heart disease that lead to heart failure.