The myocardium in the patient with congestive heart failure is abnormal and probably unable to generate sufficient chemical energy to meet the heart's mechanical needs. Such a condition of "energy starvation" would have several important implications; among these is that inotropic stimulation, by increasing energy utilization, could accelerate the progressive death of myocardial cells that characterizes end-stage heart failure. An important goal of therapy in these patients, therefore, is to reduce cardiac energy expenditure. This can be accomplished by unloading the failing heart, which has already been shown to prolong survival in patients with severe congestive heart failure. Slowing the progressive death of myocardial cells may also be accomplished by the administration of negative, rather than positive, inotropic drugs.