Prognosis in Heart Failure with a Normal Ejection Fraction

To the Editor: Recent studies have shown a poor prognosis for patients with heart failure who have a normal ejection fraction,1 a finding that differs markedly from the results of randomized, controlled trials.2,3 This discrepancy requires an explanation. Many patients with heart failure who have serious, common coexisting illnesses, such as pulmonary disease, atrial fibrillation, and renal dysfunction (all of which are both markers and mediators of a worse outcome), are excluded from randomized, controlled trials for two obvious reasons. First, heart failure with a normal ejection fraction is largely a diagnosis of exclusion, and patients with coexisting illnesses . . .