Objective To analyze the etiological changes in the elderly hospitalized patients with heart failure (HF) and investigate the strategies to prevent and treat HF. Methods A retrospective study was performed on 6 288 patients (4 001 males and 2 287 females) with a primary diagnosis of validated HF who were consecutively admitted to our hospital during the years of 1993 to 2010. The patients were divided into groups A, B and C with 6 years as interval. The etiological features and 30-day in-hospital mortality were compared in different genders and ages from the above 3 groups. Results During the period of 18 years, the number of the inpatients was increased year by year, with the proportion of women increased and men decreased, and the percentage of age 60 to 69 years old declined and over 80 years old risen. Of the 6 288 patients, the proportion of accompanied hypertension and diabetes was increased, but that with coronary artery diseases, prior myocardial infarction and cor pulmonale decreased. There was no significant change in the proportions of acute myocardial infarction, rheumatic heart disease, congenital heart disease, anemia and hyperthyroid heart disease. In the inducing factors, the rate of pneumonia and atrial fibrillation was increased, but the rate of ventricular tachycardia and ventricular fibrillation reduced. The ratio of double, triple or more etiological factors was increased with aging, but there was no significant difference over the 3 different periods. The 30-day in-hospital mortality was decreased gradually, especially in males (P＜0.01). Conclusion During the 18 years, the proportions of patients with hypertension and diabetes as etiological factors are increased significantly, but those of coronary artery disease and cor pulmonale are decreased obviously, and those of pneumonia and atrial fibrillation risen in the elderly patients with heart failure at first hospitalization. There is a significant decline in the 30-day in-hospital mortality among the cohort. The reasons of these findings are worth of further study.