The aim of this study is to assess the hypertensive remodeling and functional changes and to form a new echocardiographic grading system that reflects the severity of hypertensive heart disease. We studied 213 hypertensive and 62 normotensive subjects. Grade I subjects had no left ventricular hypertrophy (LVH) (LVMI < 125 g/m(2)), no valvular regurgitation (VR) or stenosis (VS) with normal EF, but minimal structural changes. Grade LI patients had mild to moderate LVH (125 g/m(2) > LVMI > 170 g/m(2)) without VR or VS and normal EF; Grade III patients had LVH (LVMI > 170 g/m(2)) and/or mild to moderate VR or VS with normal EF. Grade IV changes consisted of systolic dysfunction and/or severe VR or VS with LVH. Left ventricular (LV) dimensions, LVMI of the hypertensive group were higher and EF lower than the normotensive subjects (p < 0.0001, p < 0.0001, p = 0.035). Mitral early filling velocities were not different whereas late filling velocities were higher in the hypertensive group. Fibrotic, calcific changes of the mitral and aortic valves and VR were also significantly more frequent in the hypertensive group. The patients who had Grade III and IV changes were older and had higher blood pressures of longer duration as compared to grade I and II subjects. LV dimensions and LVMI increased progressively in Grade I, II, III and IV patients. We can conclude that hypertension induces a wide spectrum of changes in the LV structure and function. This echocardiographic grading system predicts the severity of hypertensive heart disease and therefore will be helpful for risk stratification of hypertensive patients.