Echocardiography allows the assessment of systolic and diastolic function and identifies many of the common causes of heart failure. 1. Visually estimate LV systolic function If normal LV systolic function, proceed to step 2. If intermediate degree of systolic dysfunction, proceed to step 3. If indeterminate, proceed to step 3. If severely reduced, proceed to step 4. 2. Evaluate diastolic function Use extreme values in the elderly. Consider ischemic heart disease. Carefully evaluate for valvular heart disease. 3. Quantitate LV systolic function Volumetric methods (modified Simpson's rule). Use harmonic imaging or contrast if poor endocardial definition. 4. Hemodynamic assessment Estimate filling pressures. Estimate the pulmonary artery pressure. Calculate cardiac output. Patients with minimally symptomatic or unsuspected LV systolic dysfunction may be identified and receive the benefits of ACE inhibitor therapy. Echocardiography is also useful for assessing prognosis and can be used serially to evaluate the effectiveness of treatment. Intracardiac filling pressures, pulmonary artery pressures, and cardiac output can be sequentially determined. We believe that all patients with heart failure should receive careful assessment with two-dimensional, M-mode, and Doppler echocardiography, especially the elderly, who have the poorest prognosis and are more likely to have diastolic dysfunction.