Congestive heart failure is a leading cause of cardiovascular morbidity and mortality, and is the main cause of hospitalization among patients older than 65 years. Moreover, its prevalence is expected to reach nearly epidemic proportions, so that the need for new treatments is clear. In this article we review current and future strategies for the treatment of systolic heart failure that are based on a better understanding of the pathophysiology of this disorder and on the results of controlled clinical trials of different treatments. Drugs under development (phase II and III clinical trials) have been classified into four main groups: neurohumoral antagonists, inotropic agents, modulators of myocardial remodeling, and future approaches to treatment such as gene therapy and anti-apoptotic drugs. We also discuss new strategies for the treatment of diastolic heart failure.