Arterial hypertension may be viewed as a generalized vascular disorder, with an imbalance between proliferation and apoptosis of vascular smooth muscle cells. As a consequence exaggerated accumulation of these cells may result leading to an encroachment of the tunica media into the lumen. This geometric abnormality of the vessel wall may play a critical role in the long-term maintenance of elevated blood pressure and development of hypertensive endorgan damage. In this short paper, we summarize data on alterations in the growth and death of vascular smooth muscle cells in the small coronary arteries in hypertension.