Today, most heart failure physicians focus on devices and transplantation; hospital-based management teams devoted only to achieving optimal medical therapy are scarce. The financial demands on heart failure specialists are enormous. A viable business plan can no longer be based on the misguided hope that payers will reimburse generously for prescriptions of digitalis and diuretics; in contrast, cardiac procedures generate meaningful revenues. A growing advocacy now encourages the use of ventricular assist devices in ambulatory patients on the basis of the dual misconceptions that the hazards are readily managed and that the clinical responses to medical therapy are poor. The biases in favor of performing procedures are so great that a National Institutes of Health–sponsored randomized trial comparing left ventricular assistance and optimal medical therapy in ambulatory patients was closed because of slow recruitment. In its place, a nonrandomized study of 200 patients (ROADMAP [Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management]) was carried out and reported major advantages in patients who chose to receive a left ventricular assist device compared with those who chose to receive optimal medical management.1 The numerous limitations of the study are beyond the scope of this article, but it is intriguing that the authors failed to identify optimal medical therapy. Patients not electing a device were prescribed guideline-based …