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Hyponatraemia is very common in heart failure (HF), especially in decompensated patients. It is associated with increased mortality and morbidity and considered a marker of advanced disease. Recognition of hyponatraemia and its causes may help guide treatment strategy. Historically, therapy has primarily focused on water restriction, decongestion with loop diuretics in case of volume overload (dilutional hyponatraemia) and sodium repletion in case of depletion. In this review, we summarise the potential benefits of established and emerging HF therapies on sodium homeostasis, with a focus on dual vasopressin antagonists, angiotensin receptor-neprilysin inhibitors, sodium-glucose cotransporter 2 inhibitors and hypertonic saline, and propose a potential therapeutic approach for hyponatraemia in HF., Competing Interests: Competing interests: AK-C has received speaker fees from Angelini Pharma, Bayer, KRKA and Servier, outside the submitted work. YM reports consulting payments from AstraZeneca, Novartis, Boehringer Ingelheim, Vifor, Bayer and Servier, outside the submitted work. FHV has received speakers' fees and fees for advisory roles from Novartis and Boehringer Ingelheim, outside the submitted work. PV declares consultancy fees from Hygeia Hospitals Group (HHG), Athens, Greece, from Servier International, Paris, France, and from Dean Medicus, UK., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)