Contrary to popular belief, population studies indicate that most elderly patients with heart failure have preserved left ventricular systolic function (i.e., presumed diastolic heart failure). Several normal aging changes may predispose older individuals to diastolic heart failure, including increased hypertrophy and stiffness of the left ventricle, increased vascular stiffness, and decreased cardiovascular reserve. Progress in diastolic heart failure has been hindered by a lack of standard case definition; absence of a readily available, reliable test to quantitate diastolic function; poor understanding of the pathophysiology of heart failure; and lack of data from randomized, controlled, multicenter trials. Typical patients are older women with chronic hypertension, left ventricular hypertrophy, chronic exercise intolerance, and occasional acute exacerbations (pulmonary edema). Although heart failure is a clinical, bedside diagnosis, echocardiography is helpful in differentiating diastolic from systolic heart failure and in ruling out other disorders. Although optimal pharmacologic therapy has not been clarified, control of blood pressure; exercise conditioning; and a multidisciplinary, case management approach seem beneficial.