OBJECTIVE: To examine the use of tests that measure ejection fraction (EF) and the use of coronary angiography among patients with an initial diagnosis of heart failure (HF). PATIENTS AND METHODS: All potential cases of incident HF in Olmsted County, Minnesota, between 1979 and 1999 were identified. In a random sample of cases validated with the Framingham criteria, we examined the frequency of tests that measure EF (echocardiography, radionuclide ventriculography, and left ventricular angiography) and coronary angiography within 90 days after diagnosis. RESULTS: A total of 655 patients with incident HF were included in the analysis. The use of tests that measure EF and coronary angiography increased early in the study period but stabilized thereafter. In the most recent years (1395-1999), EF was measured in 85% of the patients and coronary angiography performed in 12%. After adjustment for year of diagnosis, body mass index, hypertension, diabetes mellitus, smoking, hyperlipidemia, comorbidity, prior myocardial infarction, and prior angina, men were more likely than woman to have EF measured (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.01-2.16) and coronary angiography (OR, 2.61; 95% CI, 1.43-4.76). Increasing age was associated with less use of tests (OR, 0.03; 95% CI, 0.76-0.91; for EF measurement; OR, 0.72; 95% CI, 0.63-0.82; for coronary angiography for every 5-year increase in age). CONCLUSION: Among patients with HF, tests that measure EF are used substantially less than recommended, and coronary angiograms are used infrequently. Use was particularly low in women and elderly patients. Given the potential benefits of such tests, including more appropriate therapy and more objective monitoring of ventricular function, outcomes in persons with HF may be improved with more consistent use.