The potential mechanisms for the development of myocardial ischemia in hypertensive left ventricular (LV) hypertrophy involve changes in the coronary circulation characterized by a reduction of coronary vascular reserve and an acceleration of the atherosclerotic process. This combination of factors is probably reflected in the epidemiologic findings of increased coronary morbidity and mortality in hypertension, particularly when it is associated with LV hypertrophy. The failure of several antihypertensive trials to reduce coronary morbidity and mortality emphasizes the importance of early detection of significant coronary artery disease (CAD) among hypertensive patients with LV hypertrophy. A strategy to detect asymptomatic CAD based on combined probability of 2 noninvasive tests is discussed. Results obtained in hypertensive LV hypertrophy showed a 20% to 30% incidence of abnormal exercise test results, and these positive findings were predictive for the development of typical angina during a 3-year follow-up. Based on these results and reported data, it is extrapolated that patients with silent ischemia may contribute up to 40% of the coronary mortality observed in previous antihypertensive trials. These findings suggest the need for an early detection and separate follow-up of these patients with silent CAD, to better assess the influence of antihypertensive treatment on coronary morbidity and mortality.