Background Although associations between hypertension, left ventricular hypertrophy (LVH), and coronary heart disease (CHD) have been described, it is less clear whether LVH is associated with increased rates of CHD in the absence of hypertension. Methods We examined this association with Cox regression analyses of data from 7924 adults 25 to 74 years of age from the Second National Health and Nutrition Examination Survey (NHANES II) Mortality Study (1976 to 1992). Covariates included age, race, sex, history of cardiovascular diseases and diabetes, cholesterol, body mass index, blood pressure, and smoking. Results During 16.8 follow-up years, there were 462 (26%) deaths from CHD (ICD-9 410-414) and 667 (38%) deaths from diseases of the heart (ICD-9 390-398, 402, 404, 410-414, 415-417, 420-429). LVH prevalence was 13.3 per 1000 population. Hypertension prevalence was 29.1%. LVH prevalence was higher among hypertensive adults than among normotensive adults (29.9 vs 6.4 per 1000, P <.001). Persons with LVH were twice as likely to die of CHD (relative risk, 2.0; 95% confidence interval, 1.2, 3.5) and diseases of the heart (relative risk, 1.9; 95% confidence interval, 1.1, 3.0) after adjustment for hypertension and covariates. In age-adjusted predicted survival, probability plots for CHD, and diseases of the heart, normotensives with LVH had survival similar to hypertensive adults with LVH and lower survival than normotensive and hypertensive adults with no LVH. Conclusions Our results confirm previous findings that the presence of LVH is a strong predictor of future cardiovascular death. Although LVH appears to be rare among normotensives, clinicians should be aware that such individuals may have an increased risk for death similar to that of hypertensive adults with LVH. (Am Heart J 2000;140:848-56.)