Heart failure continues to be a major and growing public health problem. Guidelines for heart failure management have been primarily based on clinical trials, in which the elderly, women and minority groups were under-represented. There are major differences between patients enrolled in clinical trials and patients with heart failure at large in the community. Clinicians are faced with the challenge of deciding the best treatment for heart failure patients, in whom clinical guidelines may not fully apply. Much wider representation of minority groups, women and the elderly as well as efforts to include community heart failure patients in future clinical trials will close the gap in our knowledge, with regard to the effects of various management strategies in these patients, and will hopefully contribute to better outcome.