This study reviewed 372 male patients with congestive heart failure. Two hundred and eighty-three (77%) had congestive heart failure due to systolic dysfunction as demonstrated by radionuclide angiography. Eighty-seven (23%) with congestive heart failure were identified who had normal ejection fractions. All patients met the Framingham criteria for congestive heart failure. These 87 individuals had unrecognized diastolic heart failure. It is important to distinguish between systolic and diastolic heart failure because the pathophysiology, treatment, and prognosis differ significantly. The most frequent cause of diastolic heart failure in this study was hypertension. Diastolic dysfunction should be considered in patients with acute heart failure and severe uncontrolled hypertension, or in patients with ischemic heart disease who develop acute pulmonary edema. Patients who do not respond or deteriorate when treated for heart failure using conventional therapy may also have diastolic dysfunction. These patients warrant special recognition and tailored management.