The treatment of heart failure has advanced greatly over the past two decades. Angiotensin-converting enzyme inhibitors have become standard therapy, not only in symptomatic patients but also in those with asymptomatic left ventricular dysfunction. Diuretic regimens have become increasingly potent and sophisticated. Much of the controversy over the efficacy of digoxin has been resolved, although its effect on survival is still uncertain. Most symptomatic patients, therefore, should be treated with what has become "standard" triple therapy, but practices vary as to when and at what dose to use these medications. More problematic is how to treat the patient who remains symptomatic on a three-drug regimen, and how to manage ancillary but important issues such as arrhythmias and thromboembolic risk. This article reflects the author's personal approach to managing the patient with left ventricular systolic dysfunction in 1994.