Congestive heart failure (CHF) is a progressive disease with multiple possible causes. Systolic heart failure, defined as contractile failure of the myocardium leading to a reduced ejection fraction, is the most common type. Systolic heart failure may result from coronary artery disease, hypertension, a metabolic disorder, infection, or an infiltrative or other disease, or it may be idiopathic. Recognition of CHF can be difficult, especially in elderly patients with several medical conditions. An early clinical sign may be dyspnea on exertion. The extent of workup needed is often indicated by findings on history taking and physical examination. In all patients suspected of having new-onset CHF, a chest film, an electrocardiogram, and left ventricular ejection fraction should be obtained and a search for complicating and causative factors undertaken. Early treatment may halt the otherwise inevitable decline in cardiac function and improve prognosis.