Congestive heart failure (CHF) affects a substantial proportion of adults including those without preexisting coronary heart disease. The pathogenesis of CHF is uncertain, but microvascular disease has been hypothesized as a possible factor. To determine the relationship of retinopathy, a marker of systemic microvascular disease, to risk of CHF. Population-based, prospective 7-year cohort study in 4 US communities using the Atherosclerosis Risk in Communities Study database. Participants (n = 11,612, aged 49 to 73 years) had retinal photographs taken between 1993 and 1995. The photographs were graded according to a standardized protocol for the presence of retinopathy (eg, microaneurysms, retinal hemorrhages, soft exudates), arteriovenous nicking, focal arteriolar narrowing, and generalized arteriolar narrowing. Association between retinopathy and incident CHF, identified from hospitalization and death records. The 7-year cumulative incidence of CHF was 5.4% (492 events). Participants with retinopathy had a higher incidence of CHF compared with those without retinopathy (15.1% vs 4.8%, P<.001). After controlling for age, sex, race, preexisting coronary heart disease, mean arterial blood pressure, diabetes, glucose level, cholesterol level, smoking, body mass index, and study site, the presence of retinopathy was associated with a 2-fold higher risk of CHF (relative risk, 1.96; 95% confidence interval, 1.51-2.54). Among participants without preexisting coronary heart disease, diabetes, or hypertension, retinopathy was associated with a 3-fold higher risk of CHF (relative risk, 2.98; 95% confidence interval, 1.50-5.92). Retinopathy is an independent predictor of CHF, even in persons without preexisting coronary heart disease, diabetes, or hypertension. This suggests that microvascular disease may play an important role in the development of heart failure in the general population. Some asymptomatic persons with retinopathy on an ophthalmologic examination may benefit from further assessment of CHF risk.