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Clinically overt heart failure is common, costly, disabling, and deadly; it remains so despite the tremendous benefit of angiotensin-converting enzyme inhibitors. Better treatments for and earlier detection of heart failure are needed if the situation to improve. However, even this may not be enough. The dramatic deterioration in quality of life and prognosis when a patient progresses from asymptomatic left ventricular dysfunction to overt heart failure suggests that only a programme of screening and prevention will effectively reduce the public health burden of heart failure. Moreover, the economic consequences of developing overt heart failure suggest that such an approach is likely to be cost-effective.