The prognostic value of echocardiographic findings in patients with heart failure is well known. In contrast, few studies have addressed the changing significance of echocardiographic findings during the natural history of heart failure. Ejection fraction is useful for stratifying the cardiac risk in the early phase of the disease, but a further risk stratification among patients with ejection fraction < 30%, < 25%, or < 20% has not been observed. On the other hand, the identification of a "restrictive" left ventricular filling pattern allows to select patients with poor prognosis among those with advanced heart failure. In patients with mild to moderate heart failure, the prognostic risk should be assessed by ejection fraction and left ventricular filling pattern integrated with other echocardiographic findings such as pulmonary venous flow pattern, right ventricular function, and transmitral flow pattern changes after exercise. In conclusion, the prognostic significance of echocardiographic findings varies during the natural history of heart failure, and therefore may differ in the way it influences the management and therapeutic approach.