There has been a perceptible change in the approach to the managementof chronic heart failure (CHF) from focusing on inotropy,to a predominantly neurohormonal approach to therapeutic intervention.By contrast, in acute heart failure (AHF) the critical inabilityof the myocardium to maintain a cardiac output sufficient tomeet the demands of the peripheral circulation demands urgentintervention to restore adequate perfusion. Thus, haemodynamicconsiderations are pivotal, and the use of inotropes, pressors, andvasodilators remains widespread. This is despite concerns aboutthe potential of inotropic agents to increase mortality in somepatient populations. Current recommendations are thereforethat inotropes should be used only in selected patients, and withdrawnas soon as adequate organ perfusion is restored. The presentchapter reviews the pharmacology of positive inotropic drugs, theprinciples underlying the choice of vasoactive drugs in AHF, andpotential future developments in the field.