The understanding of heart failure has progressed in all but a linear fashion. The many false starts (due to failure to understand pathophysiology) led to therapeutic strategies that have subsequently been abandoned; these range from bloodletting— based on the belief that the heart is the source of the body’s heat—to the use of inotropic drugs, which reflected a more recent view that the major problem in this syndrome is depressed contractility. The current focus on the beneficial and deleterious features of cardiac enlargement may be more durable because it has returned our attention to maladaptive hypertrophy, whose role in determining prognosis had been recognized during the 19th century, but which today is supported by new discoveries in cell signaling and molecular biology...