Introduction Progressive development of heart failure as a consequence of many years of heart damage due to chronic ischemia Pathophysiology results from long standing coronary artery disease contractile myocytes replaced with non-contractile fibrous tissue Risk factors diabetes mellitus (most important and considered a CAD equivalent) smoking (#1 preventable factor) HTN cholesterol/lipid abnormalities LDL > 160 HDL < 35 family history age >45 (men), age >55 (women) Presentation Similar to congestive heart failure Angina patient may report history of angina due to reduced perfusion of myocardium Evaluation Chest radiograph massive cardiomegaly, pulmonary vascular congestion, interstitial pulmonary edema. Echocardiography dilated cardiomyopathy and reduced ejection fraction. Treatment Coronary artery disease risk factor management Control acute episodes of cardiac ischemia Heart failure treatment Complications Angina Heart failure potential to progress to dilated cardiomyopathy and low output heart failure Myocardial infarction Sudden cardiac death