Hypertensive left ventricular hypertrophy (LVH) has a devastating pathologic, clinical and socioeconomic impact. The recognition of the consequences of hypertension, the incidence of LVH and its subsequent long-term manifestations on our population continues to increase. Escalating amounts of medical resources are devoted towards the understanding of hypertension and its treatment, all aimed in some part at decreasing, either directly or indirectly, LVH. LVH is further complicated by relatively inexpensive and inexact clinical tools to detect its presence, namely EKG. While echocardiography has improved the recognition of LVH, more recent data demonstrate that cardiovascular MRI (CMR) is the ‘gold standard’ for its quantitation. In this review article, we aim to delineate the pathology of hypertrophy at the level of the myocyte and interstitium, incorporating new data that suggests the interstitium plays a heretofore unknown, but increasing role in the pathogenesis of LVH. We will review the pathophysiology of LVH as it relates to morbidity and mortality while reviewing the current tools for detecting LVH. Most importantly, we will review the studies that answer the question of whether LVH does matter. Specifically, we will review classical studies that, while demonstrating LVHs importance, failed to show that LVH regression led to substantial improvement in clinical outcome, while such recent studies, such as the LIFE study, have pointed to the primacy of LVH, not only as a surrogate marker for cardiovascular morbidity and mortality, but suggesting that its regression offers major impact into cardiovascular disease with potential long-term socioeconomic benefits. Herein, the impact of myocardial performance using advanced technologies such as CMR is illustrated as an ideal tool for understanding more complex pathophysiologic perturbations. Finally, and most intriguing, is a threshold of LVH in g/m2 that we suggest as a potential pharmacologic goal in order to institute a clinically meaningful impact of LVH regression.