The medical management of heart failure has undergone remarkable progress in the past 10 years. The paradigm shift is toward long-term reparative strategies that help in altering the biologic properties of the failing heart. Together with angiotensin-converting enzyme inhibitors, beta blockers have emerged as standard therapy for heart failure, especially for patients with mild to moderate heart failure. Since most of the clinical trials demonstrating the benefits of betablockers have been done in patients with mild to moderate heart failure, some controversy exists about the utility of beta-blocking agents in patients with advanced heart failure. This review will summarize the rationale and the use of beta blockers, a very challenging therapeutic strategy, in patients with severe heart failure.