Heart failure has traditionally been considered a clinical syndrome in which the symptoms define the disorder. Indeed, the clinical syndrome is often designated as “congestive heart failure” because symptoms are usually accompanied by fluid retention leading to peripheral edema and pulmonary congestion. This clinical syndrome drove its management during most of the 20th century as exercise intolerance, fatigue, and congestion were the hallmarks of the disease that required treatment. The end of the 20th century and the beginning of the twenty-first century have seen a dramatic change in our understanding and management of the disease. Although symptoms may still be the major reason patients seek medical help, we now recognize that the disease process long precedes the development of symptoms, additionally, the fact that its progression may be independent of symptom worsening or symptom relief has complicated the clinical understanding of the disease. Structural changes in the left ventricle are key to this new insight into the syndrome (1).