Background Predicted left ventricular (LV) mass for sex, height^2.7, and hemodynamic load can be used as an intrapatient reference for the observed LV mass. The ratio of observed/predicted LV mass may allow more physiologically correct comparisons of LV geometry, systolic and diastolic functions, and hemodynamics among hypertensive patients. Methods We studied 659 participants in the LIFE (Losartan Intervention for Endpoint Reduction in Hypertension) study with both electrocardiographic and echocardiographic LV hypertrophy (68% of the echocardiographic cohort) without previous myocardial infarction. LV mass was predicted by an equation including sex, stroke work, and height^2.7. Observed/predicted LV mass >128% defined inappropriate LV hypertrophy (iLVH). Relative wall thickness ≥0.43 defined concentric LV geometry. Systolic myocardial dysfunction was assessed by midwall mechanics and abnormal LV relaxation by isovolumic relaxation time (IVRT). Results Compared with patients with appropriate LV hypertrophy (aLVH), those with iLVH had higher body mass index, LV mass index, relative wall thickness, prevalences of systolic myocardial dysfunction and prolonged IVRT and lower end-systolic stress and cardiac index. Patients with eccentric iLVH had the highest wall stress and lowest ejection fraction; 43% had systolic myocardial dysfunction. Of patients with concentric iLVH, 79% had systolic myocardial dysfunction but normal ejection fraction and the lowest wall stress. Systolic myocardial dysfunction was present in 12% with concentric aLVH and none with eccentric aLVH. Prevalence of prolonged IVRT was high in all 4 groups (65% to 77%). Cardiac index was similarly lower with concentric or eccentric iLVH than with aLVH. Conclusions Among hypertensives with LV hypertrophy, iLVH identified cardiac phenotypes with a high prevalence of myocardial systolic dysfunction. (Am Heart J 2001;141:784-91.)