The syndrome of congestive heart failure results from a primary loss of contractile function of the myocardium, leading to diminished stroke volume, cardiac output and arterial pressure. Reflex compensatory mechanisms of the cardiovascular system include the Frank-Starling reflex, increased sympathetic activity, salt and water retention and, finally, myocardial cell hypertrophy. These compensatory responses are initially beneficial, but ultimately lead to the adverse symptoms and signs of congestive heart failure. Therapeutic strategies have included inotropic support with digitalis glycosides, reducing systemic and pulmonary venous congestion with diuretics and unloading of left ventricular ejection with vasodilators. For ongoing therapy the angiotension converting-enzyme inhibitors, specifically captopril, appear to produce the most beneficial long-term clinical responses in recent controlled studies. Digitalis, diuretics and vasodilators have many limitations in the treatment of heart failure, the most challenging of which is the wide variability of response rates for individual patients. The new oral inotropic agents have beneficial hemodynamic effects in patients with severe heart failure for whom other therapies have failed, but at the present time have not been shown in controlled studies to produce clinical improvement with long-term therapy.