Despite the epidemiologic importance, large investments, and careful design, recent results of heart failure (HF) trials have been unable to demonstrate significant treatment improvements. This shortcoming has led to a reassessment of research methodology, particularly related to sample size and costs, for which end-point selection is a main issue. In comparing interventions in clinical trials, surrogate end points may be used to reduce the costs. To this end, ongoing research into the roles of imaging biomarkers as reliable surrogate end points may lead to better clinical trial design and more efficient development of new therapies for HF.