Hypertension (HTN) is the primary population-attributable risk for the development of heart failure (HF); a disease with devastating consequences particularly in urban centers where morbidity and mortality are more pronounced. The Framingham Risk Profile (FRP) is widely used to quantify risk for cardiovascular disease (CVD), but its applicability in an urban population who utilize the emergency department (ED) for primary care is unknown. The objective of this study is to evaluate FRP scores in ED patients with asymptomatic HTN and subclinical hypertensive heart disease (SHHD). This is a substudy of a prospective randomized clinical trial designed to evaluate optimal blood pressure (BP) targets. Eligible patients were screened with echocardiography for the presence of SHHD and FRP scores were calculated. One hundred forty-nine patients enrolled in the study, 133 (89.2%) of whom had detectable SHHD. Mean [SD] calculated FRP scores were statistically similar for patients with SHHD versus those without (general CVD: 20.2 [8.5] vs. 15.6 [8.7]; P = 0.13 and HF calibrated: 2.4 [1.0] vs. 1.8 [1.0]; P = 0.12) corresponding to a calculated risk of 15%–30% for subsequent development of CVD. The HF-specific risk score for patients with SHHD was 2.4, which equates to a 2.5% risk of HF development in 10 years. The FRP correctly identified those with SHHD as high-risk for general CVD but appeared to underestimate the likelihood of HF. Recalibration of the HF adjustment factor and inclusion of additional data elements such as echocardiography is needed to enhance applicability of the FRP in this setting.