There is an impressive evidence base for the presence of myocardial ischemia in patients who have hypertension. This relationship ranges from the obvious association with obstructive coronary artery disease to more subtle mechanisms related to hemodynamic, microcirculatory, and neuroendocrine abnormalities. All of these factors serve to destabilize the critical balance between myocardial oxygen supply and demand. We have at our disposal a range of sophisticated investigations that allow us to demonstrate the presence and extent of the ischemia and therefore to target specific therapies to reduce the risk to these patients. Achieving target blood pressure and managing all reversible components of the patient's cardiovascular risk status help to minimize the clinical sequelae of myocardial ischemia in this vulnerable population. © 2009 Elsevier Inc. All rights reserved.