In developed countries, arterial hypertension carries the greatest population-attributable risk of heart failure. Overall, it is expected that almost 30% of hypertensive patients will develop heart failure over time. High blood pressure has a strong impact on the heart. The morphological and functional transformations induced by hypertension can promote not only left ventricular hypertrophy but also myocardial ischemia or rhythm disorders, each of them representing a potential contributor to the occurrence of heart failure. Left ventricular remodeling mediated by hypertension implies not only an increased size of myocytes but also the process of fibrogenesis. Myocardial ischemia has as its substrate an imbalance between demand and intake, and the appearance of microvascular dysfunction or atherosclerotic lesions in the epicardial coronary arteries, as well. Hypertensive patients usually develop heart failure with preserved ejection fraction. Although diastolic dysfunction can precede left ventricular hypertrophy, it is usually associated with it. The risk of heart failure increases greatly after the appearance of left ventricular hypertrophy. According to the complexity of hypertensive heart disease the diagnostic workup of hypertensive patients starts with electrocardiography and rest transthoracic echocardiography, but must be extended in specific cases with the imagistic evaluation of coronary arteries (angio-CT or conventional angiography), stress tests for myocardial ischemia or even evaluation of microvascular function and cardiac magnetic resonance imaging. Left ventricular hypertrophy, especially left ventricle fibrosis and left atrium dilatation are the main prognostic parameters that augment the risk of heart failure. With each 10 mmHg decrease in systolic blood pressure, the risk of HF falls by 12% making it possible to achieve a global reduction in the occurrence of HF by 50% or even more with antihypertensive treatment. Reducing the risk of heart failure involves the effects of antihypertensive treatment on left ventricular hypertrophy, coronary artery disease, mostly acute events, and the occurrence of atrial fibrillation. Thiazides and thiazide-like diuretics are likely the ideal agent for heart failure prevention followed by ACEi/ARBs.