The management of ventricular arrhythmias in patients with heart failure continues to pose many challenges. Three principles of therapy can be identified: (1) Empiric therapy is not warranted for asymptomatic ventricular arrhythmias. (2) Therapy for asymptomatic ventricular arrhythmias must be individualized. Appropriate management of the underlying cardiac disease is critical, and careful identification of therapeutic goals is necessary. (3) Patients at high risk should be included in prospective, controlled clinical trials whenever possible.