Left ventricular hypertrophy (LVH) is more than just an adaptive response to hypertension. It predicts a poor prognosis independently of the blood pressure (BP) level. There is increasing evidence from studies such as Heart Outcomes Prevention Evaluation (HOPE) and Losartan Intervention For Endpoint reduction in hypertension (LIFE) that LVH should be a target for treatment, above and beyond BP control. It is likely that drugs blocking the renin-angiotensin-aldosterone system cause greater regression of LVH than other agents and this is probably the mechanism that explains the superiority of losartan over atenolol in the LIFE study. In order to achieve the stringent BP goals suggested by modern guidelines, most patients will require multiple antihypertensive agents and the clinical choices relate more often to which combinations of drugs are most appropriate, rather than which single drug is the best. Tight BP control should be the first priority and this is likely to lead to regression of LVH.