Heart failure is a complex syndrome; therapy should be aimed at the independent goals of prolonging life and of improving symptoms and quality of life. Some therapies are effective in achieving one goal but not the other. Short-term symptomatic relief may relate to alleviation of haemodynamic abnormalities and of congestion, whereas slowing progression of the disease and reducing mortality involve neurohormonal mechanisms, left ventricular remodelling and arrhythmia generation. Current therapy is moderately effective on these end-points, but newer approaches to management are necesssary to produce more profound improvements in morbidity and mortality.