Background: Available data on the prognosis of heart failure (HF) patients are predominantly limited to patients diagnosed at time of hospitalization. Aims: To describe the long-term survival of incident HF patients and identify clinical characteristics associated with mortality. Methods: The Second Australian National Blood Pressure Study (ANBP2) randomized 6083 hypertensive subjects aged 65-84 years to angiotensin-converting enzyme (ACE) inhibitor or thiazide diuretic–based therapy and followed them for a median of 4.1 years. One hundred forty-five participants who developed HF and 5938 who remained free from HF during the trial period were followed for a median of 6.7 years during a posttrial follow-up. Results: Three quarters, 110 (76%) of HF patients had died at the end of the follow-up. The five- and ten-year survival rates following HF diagnosis during the trial period were 37% and 15%, respectively, in men, compared with 60% and 33%, respectively, in women. In non–heart failure participants, the five- and ten-year survival rates, following enrollment into the study, were 92% and 76%, respectively. Mortality following HF diagnosis increased with advancing age (HR = 1.09, 95% CI: 1.04-1.33). In addition, male gender and preexisting diabetes were predictive of mortality, while ACE inhibitor–based therapy for the initial trial was associated with 39% decrease (HR = 0.61, 95% CI: 0.41-0.91) in mortality compared with a thiazide diuretic–based regimen. Conclusions: Long-term survival in elderly HF patients is poor, especially in men. Mortality in HF patients increased progressively with advancing age, while allocation to the ACE inhibitor–based regimen for the initial trial significantly improved HF outcome.