Background: ST depression and T-wave inversion (TWI) are classic ECG strain patterns that indicate left ventricular hypertrophy (LVH) and a poor prognosis. The relationship between strain and increased left ventricular (LV) mass and its relationship to ischemic heart disease (IHD), however, hasn't been thoroughly studied. Objectives:  The aim of the current work was to assess if hypertensive cases with a strain pattern on ECG have more ischemic changes at the level of the myocardium or if it is just an electrical phenomenon associated with hypertension (HTN). Patients and methods: The current study comprised 100 hypertensive cases who were undergone coronary angiography for suspected angina pectoris and revealed normal coronaries, and 15 age and sex-matched normotensive health volunteers (control group). Patients were further divided into 2 groups; Group I: included 50 hypertensive patients with strain criteria by ECG, and Group II: included 50 hypertensive patients without strain criteria. A conventional echocardiogram was performed using M-mode, 2D, Doppler, and Tissue Doppler, and then myocardial strain measured by 2D speckle tracking echocardiography (STE) was used to evaluate the layers of the myocardium. Results: The layer-specific strain (LSS) was significantly lower in both hypertensive groups compared to the controls in all three layers (endocardium, myocardium, and epicardium). The LSS was significantly decreased in GI cases with strain ST-T changes than in GII cases with no strain ST-T changes. The endocardial layer was much more affected than the mid-myocardial and epicardial layers; in GI, the endocardial layer's P-value was <0.001, while in the mid-myocardial layer the P-value was <0.05), and in the epicardial layer P-value was <0.05. Conclusion: It could be concluded that hypertensive patients with LVH and strain pattern have more ischemic changes than hypertensive patients without strain and the ischemic changes are more profound at the level of the endocardium.