Background: Patient-reported health status is highly valued by clinicians, investigators and payers as a key measure of health care quality. Little is known about the extent to which patient-reported health status is determined by subjective perception vs. objective measures of disease severity. We sought to compare the associations of depressive symptoms and objective measures of cardiac disease severity with perceived New York Heart Association (NYHA) functional classification in patients with stable ischemic heart disease (IHD). Methods: We assessed depressive symptoms (using the 9-item Patient Health Questionnaire), objective measures of cardiac disease severity (exercise capacity, left ventricular ejection fraction (LVEF), left ventricular hypertrophy (LVH), diastolic function, and inducible ischemia), and perceived NYHA symptom burden in 1023 patients with stable IHD. We compared the extent to which patient-reported NYHA functional classification was influenced by depressive symptoms vs. objective measures of disease severity. We also evaluated perceived NYHA functional classification as a predictor of and subsequent hospitalization for heart failure (HF), both before and after adjustment for depressive symptoms. Results: Patients with depressive symptoms were more likely to report poor (Class III or IV) NYHA functional status than those without depressive symptoms (44% vs. 17%; p<0.001). After adjustment for traditional risk factors, comorbid conditions, and objective measures of cardiac disease severity, worse NYHA symptom burden was most strongly predicted by depressive symptoms (OR 2.74, 95% CI 1.94-3.87), followed by poor treadmill exercise capacity (OR 2.31, 95% CI, 1.68-3.18), history of HF (OR 1.53, 95% CI, 1.08-2.17), LVEF <50% (OR 1.39, 95% CI, 0.87-2.22), and LVH (OR 1.01, 95% CI, 0.77-1.33). NYHA functional classification was significantly predictive of HF hospitalization even after adjustment for depressive symptoms (HR 1.72, 95% CI 1.46-2.02, p<0.001). Conclusions: Depressive symptoms were stronger predictors of perceived symptom burden than objective measures of disease severity. This suggests that depressive symptoms should be considered in the differential diagnosis of poor NYHA functional classification among patients with IHD.