Previous studies have pointed out that congestive heart failure (CHF) with normal ejection fraction presents a uniform clinical profile that is indistinguishable from heart failure with low ejection fraction. Thirty-six patients with systemic hypertension who had recently experienced CHF with normal ejection fraction (> or = 50%) and no clinical history of ischemic cardiomyopathy were studied. The patients were divided into 2 groups according to degree of echocardiographic hypertrophy: group A (19 patients) with a ventricular mass/volume ratio > 1.8, and group B (17 patients) with a ratio < 1.8. Group A patients had a higher ejection fraction (67 +/- 6 vs 57 +/- 3%, p < 0.01), smaller ventricular diameters and a lower thallium-201 positive rate at peak stress (10 vs 70% in group B, p < 0.001), with 8 of 10 showing severe coronary stenosis. Clinically, group A had a more frequent audible fourth sound (79 vs 17%, p < 0.001), a low incidence of audible third sound (5 vs 55%, p < 0.001) and a cardiothoracic ratio < or = 0.5 (63 vs 17%, p < 0.01). The degree of radionuclide-detected resting diastolic dysfunction and exercise intolerance was similar in both groups. In conclusion, CHF with normal ejection fraction in hypertensive patients presents 2 different profiles: one characterized by severe hypertrophy and the other by a high rate of myocardial regional ischemia. Therapy should be aimed at pathophysiologic regression of the hypertrophy in the first case, and at improvement of the ischemia in the second.