© Springer Science+Business Media New York 2014. In older Americans, hypertension is the most important risk factor for cardiovascular disease (CVD) and is present in 74 % of patients with incident heart failure (HF). The prevalence of a normal left ventricular (LV) ejection fraction (EF) associated with HF or diastolic HF (DHF) increases with age, is higher in older women than in older men, and is present in approximately half of older HF patients. Hypertension is more common in patients with DHF than in systolic HF or HF with a low LVEF. In older adults with hypertension, LV diastolic dysfunction leads more often to HF than does LV systolic dysfunction. Hypertension can progress to HF through different pathways. These include development of LV hypertrophy, impaired LV filling, and increased wall thickness. DHF in older adults is probably related to progressive fibrosis and myocardial stiffening associated with age, hypertension, LV hypertrophy, coronary artery disease, and diabetes mellitus. This chapter will discuss LV diastolic dysfunction, LV hypertrophy, prevention of HF by antihypertensive drug therapy in older adults, DHF, and prevention and treatment of DHF in older adults with hypertension.