Background: Hypertension is a prevalent and well-recognized cardiovascular risk factor that predisposes to the development of left ventricular hypertrophy (LVH), coronary heart disease and systolic and diastolic dysfunction. The presence of high left ventricular (LV) mass or a high left ventricular mass index (LVMI) is reportedly an independent predictor of increased cardiovascular morbidity and mortality both in the general populations and in hypertensive populations. Ambulatory ECG (Holter) monitoring is a very effective way of measuring ischemic events over 24 hrs. period, it has advantages over exercise testing. Objective: To assess presence of silent ischemia in type 2 diabetic and hypertensive patients with LVH in comparison to type 2 diabetic and hypertensive patients with normal LV geometry. Patients and methods: This study was a pilot one that was carried out on 60 type 2 diabetic and hypertensive patients (28 males and 32 females aged 53.5 ± 10.4). Thirty cases had LVH and the other 30 had normal geometry. This study was conducted from October 2018 to February 2020. All patients were subjected to complete history taking including comorbidities, risk factors and full clinical examination. Patients with baseline ST segment depression > 2 mm in 2 consecutive leads, mitral stenosis, aortic stenosis, congenital heart disease, atrial fibrillation, prior myocardial infarction (MI) or coronary artery bypass graft surgery (CABG), pericardial diseases, advanced renal or hepatic disease were excluded. Echocardiography was done and LV assessment alongside with measuring LVMI. Also, all patients were investigated by 24 hours continuous holter monitoring, and all of them underwent further investigation to assess the presence of CAD either by coronary angiography or multislice CT coronary angiogram. Results: There was a statistically significant relationship between the presence of LVH and positive Holter findings for silent ischemia.      Out of 30 patients with normal geometry, 25 patients (83.3%) were negative and 5 patients (16.7%) were positive for silent ischemia. Out of the other 30 patients with abnormal geometry (LVH), 9 patients (30%) were negative and 21 patients (70%) were positive for silent ischemia. In 10 patients with mild LVH, 4 patients (40%) were negative and 6 patients (60%) were positive for silent ischemia. Out of 14 patients with moderate LVH, 4 patients (28.6%) were negative and 10 patients (71.4%) were positive for silent ischemia. As regards the last 6 patients with severe LVH, 1 patient (16.7%) was negative and 5 patients (83.3%) were positive for silent ischemia. Conclusion: The prevalence of silent ischemia markedly increased amongst diabetic and hypertensive patients with LVH in comparison to those with normal left ventricular geometry. The incidence of silent ischemia increased with increased LVMI. Ambulatory ECG monitoring may have a use in the identification of those at greatest risk of cardiovascular complications and sudden death.