A number of large randomized, placebo-controlled mortality trials provided evidence-based data to guide the treatment of patients with systolic heart failure, but, with one exception, similar trials in patients with diastolic heart failure (DHF) either are not yet completed or have not been conducted at all. However, randomized outcomes trials conducted in patients with hypertension with and without left ventricular hypertrophy and in patients with vascular diseases at high risk for cardiovascular events provide a strong rationale for long-term angiotensin-converting enzyme inhibition or angiotensin receptor blockade in patients with DHF. The treatment of patients with acutely decompensated DHF remains purely empirical. Thus, a pragmatic approach to the treatment of acutely decompensated DHF that includes the use of B-type natriuretic peptide is presented.