Patients with essential hypertension are at an increased risk for sudden cardiac death. As is the case with other complications of hypertension, this increased risk reflects the interplay between a higher prevalence of coronary artery disease and the pathophysiologic consequences of left ventricular hypertrophy. The presence of coronary artery disease is the most important factor, but left ventricular hypertrophy also results in changes in the coronary circulation that predispose to myocardial ischemia, and is also associated with an increased frequency of ventricular arrhythmias. Hypertension itself is associated with changes in the autonomic nervous system that may predispose to sudden death. It is therefore likely that the mechanisms responsible for sudden death are multifactorial, but it is also clear that effective antihypertensive therapy will prevent or mitigate these predisposing factors and will reduce the incidence of this and other cardiac complications.