Diastolic heart failure (DHF) is now firmly established as a significant contributor to the heart failure syndrome. However, compared to the better studied systolic dysfunction heart failure relatively little is known about this form of the syndrome. Epidemiological data have demonstrated that it is particularly important in the elderly likely reflecting the combination of several changes occurring in the myocardium occurring with advancing years, including progressive fibrosis and stiffening of the myocardium, the impact of hypertension over the years and the increased likelihood of ischaemic heart disease. This review will focus on the relevant aetiological factors in DHF, possible pathophysiological mechanisms and outline new and evolving therapeutic strategies for this problem.