Chronic decompensated heart failure (HF) is costly to manage because of frequent episodes of acute decompensation that result in hospitalization. Patients with chronic decompensated HF may have inadequate hemodynamic responses or limited tolerance of oral HF medications and therefore may require parenteral administration of vasoactive agents. Intermittent infusions of inotropic agents are no longer recommended, but preliminary data suggest that intermittent nesiritide may be a safe and effective adjunct to oral drug therapy for select patients at risk for further episodes of decompensation. In other patients, nonpharmacologic approaches used in combination with drug therapy may help improve functional status and reduce mortality.