Hypertensive heart disease (HHD) causes structural changes (e.g., fibrosis) that result in diastolic and systolic myocardial dysfunction. Alterations of 31P metabolism and cardiac energy impairments were assessed in patients with HHD by MR spectroscopy (MRS) and correlated with left ventricular systolic function. Thirty-six patients with HHD and 20 healthy controls (mean age 35.2±10.7 years) were examined with 31P-MRS at 1.5 T by using an ECG-gated CSI sequence. Twenty-five patients (mean age 64.3±9.3 years) had diastolic dysfunction, but preserved systolic function (HHD-D), whereas 11 patients (62.3±11.4 years) suffered from additional impaired systolic function (HHD-S). In both patient groups, the PCr/γ-ATP ratio was lower than in the controls (controls: 2.07±0.17; P<0.001), and in HHD-S was lower than in HHD-D (1.43±0.21 vs. 1.65±0.25; P=0.012). PCr/γ-ATP ratios were linearly correlated with LVEF (Pearson's r: 0.39; P=0.025). In the HHD-S group, the PDE/γ-ATP ratio was significantly lower (0.56±0.36) than in the controls (1.14±0.42; P=0.001). In contrast to the group of HHD-D patients, whose slightly decreased PCr/γ-ATP ratios compared to controls may be explained by age differences, the more distinct changes observed in HHD-S patients indicate an altered energy metabolism. The observed metabolic changes were related to functional impairments, as indicated by a reduced LVEF. Reduced PDE/ATP ratios indicate changes in the phospholipid metabolism.