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A recent study showed that Native Hawaiians and Other Pacific Islanders (NHOPI) with ischemic stroke are younger and have a higher burden of cardiovascular risk factors compared to whites and Asians. However, a detailed assessment of the degree of hypertensive heart disease using echocardiogram data among this multi-ethnic young adult population has not been studied. The objective of this study was to assess ethnic differences in the echocardiographic findings of hypertensive heart disease among young adults who were hospitalized for ischemic stroke. We hypothesized that NHOPI young adults with ischemic stroke have a higher prevalence of echocardiographic findings of hypertensive heart disease compared to whites and Asians. We conducted a retrospective study of all young adults (age ≤ 55 years) who were hospitalized at the Queen’s Medical Center in Honolulu, HI between 2008 and 2012 with an admission diagnosis of ischemic stroke. Patients with an ethnicity other than white, Asian, or NHOPI were excluded. Echocardiograms for each patient were reviewed. Left ventricular mass was estimated by the Devereux formula. Early (E) and late (A) transmitral diastolic flow, and mitral medial annulus early diastolic velocities (E’) were recorded; and E/A and E/E’ were calculated as measures of diastolic dysfunction and LV filling pressures. A total of 259 patients (44% NHOPI, 36% Asians, and 19% whites) were included in the study. The overall mean age was 47.1 ± 7.7 years with 34% women. NHOPIs had a higher LV mass (248.9 ± 94.8 g), LV mass index (121.5 ± 41.4 g/m2), and mitral E/E’ values (15.5 ± 9.3) compared to whites (218.6 ± 74.6 g, 107.9 ± 34.2 g/m2, 11.5 ± 4.6, all P <0.05) and Asians (191.3 ± 61.5 g, 106 ± 32.2 g/m2, 12.4 ± 5.8, all P <0.01). NHOPIs had more severe diastolic dysfunction and relative wall thickness (all P <0.05) compared to Asians but not whites. Overall, NHOPIs compared to whites and Asians had 8% compared to 10% and 10.6% with normal geometry, 39% compared to 50% and 47.9% with concentric remodeling, 53% compared to 40% and 41.5% with hypertrophy. Left atrial enlargement was seen in 24% of the total population. In conclusion, this study shows that among young adults with ischemic stroke, NHOPIs have a higher burden of hypertensive heart disease compared to whites and Asians.