Electrocardiogram (ECG) is the most common method for assessment of left ventricular hypertrophy (LVH) in contemporary clinical trials. However, our understanding of the relation between hypertension and LVH is based on studies used imaging to ascertain LVH. To fill this gap in knowledge, we examined the interrelationships between hypertension, ECG-LVH and cardiovascular disease (CVD) mortality in 6,105 patients free of CVD who were followed for 14.0 years (median). The was an exponentianl ECG-LVH prevalence rates (2.40%, 4.45%, 5.75%, 8.51%, 14.38%) were exponentially increases as systolic blood pressure increases (<120 mm Hg, 120 to 129 mm Hg, 130 to 139 mm Hg, 140 to 159 mm Hg, >160 mm Hg, respectively); trend p value <0.001. Hypertension was associated with more than double the risk of ECG-LVH (odds ratio (95% confidence interval [CI]) 2.45 [1.83, 3.30]), and each standard-deviation increase in systolic blood pressure (19 mm Hg) was associated with 49% increased odds of ECG-LVH (odds ratio [95% CI] 1.49 [1.38, 1.61]). During follow-up, 733 CVD-deaths occurred. In separate Cox models, both ECG-LVH and hypertension were associated with CVD mortality (hazard ratio [95% CI] 1.39 [1.07, 1.81] and 1.39 [1.18, 1.62], respectively). However, when ECG-LVH and hypertension were entered together in the same model, the risk of CVD mortality was essentially unchanged for hypertension after adjusting for ECG-LVH, but markedly attenuated for ECG-LVH after adjusting for hypertension. In conclusion, the relation between hypertension and ECG-LVH follows a similar pattern to that reported in literature for imaging-LVH which provides support for the current practice of using ECG for assessment of LVH in contemporary hypertension clinical trials. The inability of ECG-LVH to explain the association between hypertension and CVD mortality suggests that LVH is only one of many factors by which hypertension exerts its impact on CVD.