Chronic heart failure is a progressive and life-limiting syndrome that is caused by a failure of the heart to pump blood around the body effectively. It frequently leads to a range of distressing symptoms, such as breathlessness, fatigue and fluid retention. Chronic heart failure can be caused by a variety of cardiac diseases, but is commonly linked to coronary heart disease and hypertension. In response to these, the body initiates a series of compensatory mechanisms, which ultimately become maladaptive, and the manipulation of these mechanisms is the cornerstone of pharmacological management of the condition. This article explains the compensatory mechanisms that occur in chronic heart failure and outlines the medicines commonly used in its management.