Background When the decision is made to proceed with cardiac transplantation, the risk/benefit ratio for continued medical therapy in that particular patient must be weighed against the risk/benefit ratio associated with cardiac transplantation. This can only be accomplished while the patient is on maximal medical therapy. Methods To better define the appropriateness of patients being referred for consideration of transplant, we examined the records of 100 consecutive adult patients referred to a cardiac transplant program. Results Two of five patients referred for transplantation had at least one contraindication for transplantation. Twenty percent of the patients were not treated with angiotensin-converting enzyme inhibitors and did not have any documented reason for undertreatment. Of those deemed too well for cardiac transplantation, 84% were alive and either class I or II (mean follow-up 21 months). Conclusions We found the majority to be undertreated or with an absolute contraindication to transplantation. Of those deemed too well for transplantation after appropriate treatment, 84% were alive and well. (Am Heart J 2000;140:857-60.)