Current treatment goals in heart failure (HF) aim to improve both survival and quality of life (QoL) of patients. In this brief communication, we reviewed randomized controlled trials that assessed the impact of pharmacological treatment on QoL, and we discussed some methodological limitations of QoL assessment in HF. Studies that assessed QoL with a disease-specific questionnaire were included. We found that at present there is a paradox in HF treatment. Life prolonging therapies, such as angiotensin-converting-enzyme-inhibitors, and angiotensin receptor blockers improve modestly or only delay the progressive worsening of QoL in HF. Treatment with beta blockers does not affect QoL in any way. However, this neutral effect of beta blockers may also be due to some methodological limitations, such as the small number of patients included in beta blocker trials or the short duration of follow-up. Disease-specific questionnaires may also have some limitations, e.g. are not sensitive enough to detect small changes in QoL. On the other hand, therapies that significantly improve QoL in HF (e.g. inotropic agents) do not seem beneficial in relation to survival. We conclude that QoL in HF remains an open field, in which new therapies but also clarification of methodology is required. In the mean time, the use of life prolonging therapies appears as a safe measure to modestly improve or maintain QoL.