Randomised controlled trials (RCTs) in heart failure (HF) have progressively broadened their primary endpoints over recent decades. Early landmark HF trials demonstrated the life-saving effects of new therapies using all-cause mortality as the definitive endpoint. As HF therapies improved survival, trial designers incorporated additional endpoints such as HF hospitalisations and quality of life. Most recently, advances in digital health have introduced wearable devices for collecting digital endpoints, enabling continuous monitoring of patient activity and physiology. This review critically examines the evolution of HF trial endpoints from a sole focus on mortality alone to modern composite and patient-reported outcomes and discusses the current challenges and opportunities of using wearable-derived endpoints in HF RCTs. Finally, we consider future directions for HF trial methodology, including regulatory and methodological considerations for integrating novel digitally collected endpoints alongside traditional measures to enhance a broad evaluation of new therapies.