OBJECTIVES To assess the consequences of malignant hypertension and its evolution with antihypertensive treatment. BACKGROUND Malignant hypertension can be considered as a model of the effects of very high blood pressure and renin-angiotensin levels on target organs. However, the consequences on the heart have been little studied. METHODS The consequences of malignant hypertension on left-ventricular function and its evolution with treatment were assessed with echocardiography in a prospective study between January 2004 and June 2009. RESULTS During the study period, 46 patients were referred to our unit for malignant hypertension of whom 25 could be included in the echocardiographic study. These patients showed at baseline important left-ventricular hypertrophy and alteration in systolic function. Global longitudinal strain was the most sensitive tool to assess impaired systolic function and was significantly reduced in 13 patients (<12.8, 52%). Short-term follow-up (1-3 months) showed a rapid improvement in systolic function together with significant hypertrophy regression. With a follow-up of 11 months on average all patients had recovered a normal global longitudinal strain with further but incomplete regression of hypertrophy. CONCLUSIONS Our study highlights the significant impact of malignant hypertension on systolic function of the left ventricle, and the ability of this ventricle to quickly recover normal systolic function under antihypertensive treatment.